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Maher M, Schweizer TA, Macdonald RL. Treatment of Spontaneous Subarachnoid Hemorrhage: Guidelines and Gaps. Stroke 2020; 51:1326-1332. [PMID: 31964292 DOI: 10.1161/strokeaha.119.025997] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Tom A Schweizer
- Neuroscience Research Program, Li Ka Shing Knowledge Institute, Institute of Medical Science (T.A.S.)
| | - R Loch Macdonald
- Division of Neurosurgery, Departments of Surgery and Physiology, Keenan Research Centre for Biomedical Science, St Michael's Hospital, University of Toronto, Ontario, Canada (R.L.M.)
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52
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Darkwah Oppong M, Gümüs M, Pierscianek D, Herten A, Kneist A, Wrede K, Barthel L, Forsting M, Sure U, Jabbarli R. Aneurysm rebleeding before therapy: a predictable disaster? J Neurosurg 2019; 131:1473-1480. [PMID: 30544356 DOI: 10.3171/2018.7.jns181119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current guidelines for subarachnoid hemorrhage (SAH) include early aneurysm treatment within 72 hours after ictus. However, aneurysm rebleeding remains a crucial complication of SAH. The aim of this study was to identify independent predictors allowing early stratification of SAH patients for rebleeding risk. METHODS All patients admitted to the authors' institution with ruptured aneurysms during a 14-year period were eligible for this retrospective study. Demographic and radiographic parameters, aneurysm characteristics, medical history, and medications as well as baseline parameters at admission (blood pressure and laboratory parameters) were evaluated in univariate and multivariate analyses. A novel risk score was created using independent risk factors. RESULTS Data from 984 cases could be included into the final analysis. Aneurysm rebleeding occurred in 58 cases (5.9%), and in 48 of these cases (82.8%) rerupture occurred within 24 hours after SAH. Of over 30 tested associations, preexisting arterial hypertension (p = 0.02; adjusted odds ratio [aOR] 2.56, 1 score point), aneurysm location at the basilar artery (p = 0.001, aOR 4.5, 2 score points), sac size ≥ 9 mm (p = 0.04, aOR 1.9, 1 score point), presence of intracerebral hemorrhage (p = 0.001, aOR 4.29, 2 score points), and acute hydrocephalus (p < 0.001, aOR 6.27, 3 score points) independently predicted aneurysm rebleeding. A score built upon these parameters (0-9 points) showed a good diagnostic accuracy (p < 0.001, area under the curve 0.780) for rebleeding prediction. CONCLUSIONS Certain patient-, aneurysm-, and SAH-specific parameters can reliably predict aneurysm rerupture. A score developed according to these parameters might help to identify individuals that would profit from immediate aneurysm occlusion.
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Affiliation(s)
| | | | | | | | | | | | | | - Michael Forsting
- 2Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
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Nichols LJ, Gall S, Stirling C. Determining rural risk for aneurysmal subarachnoid hemorrhages: A structural equation modeling approach. J Neurosci Rural Pract 2019; 7:559-565. [PMID: 27695237 PMCID: PMC5006469 DOI: 10.4103/0976-3147.188627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An aneurysmal subarachnoid hemorrhage (aSAH) carries a high disability burden. The true impact of rurality as a predictor of outcome severity is unknown. Our aim is to clarify the relationship between the proposed explanations of regional and rural health disparities linked to severity of outcome following an aSAH. An initial literature search identified limited data directly linking geographical location, rurality, rural vulnerability, and aSAH. A further search noting parallels with ischemic stroke and acute myocardial infarct literature presented a number of diverse and interrelated predictors. This a priori knowledge informed the development of a conceptual framework that proposes the relationship between rurality and severity of outcome following an aSAH utilizing structural equation modeling. The presented conceptual framework explores a number of system, environmental, and modifiable risk factors. Socioeconomic characteristics, modifiable risk factors, and timely treatment that were identified as predictors of severity of outcome following an aSAH and within each of these defined predictors a number of contributing specific individual predictors are proposed. There are considerable gaps in the current knowledge pertaining to the impact of rurality on the severity of outcome following an aSAH. Absent from the literature is any investigation of the cumulative impact and multiplicity of risk factors associated with rurality. The proposed conceptual framework hypothesizes a number of relationships between both individual level and system level predictors, acknowledging that intervening predictors may mediate the effect of one variable on another.
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Affiliation(s)
- Linda Jayne Nichols
- School of Health Sciences, Faculty of Health Science, University of Tasmania, Hobart Tasmania, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart Tasmania, Australia
| | - Christine Stirling
- Menzies Institute for Medical Research, University of Tasmania, Hobart Tasmania, Australia
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The path from ictus to Neurosurgery: chronology and transport logistics of patients with aneurysmal subarachnoid haemorrhage in the South-Eastern Norway Health Region. Acta Neurochir (Wien) 2019; 161:1497-1506. [PMID: 31197472 DOI: 10.1007/s00701-019-03971-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/04/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Guidelines state that patients with aneurysmal subarachnoid haemorrhage (aSAH) require neurosurgical treatment as early as possible. Little is known about the time frame of transport from the ictus scene to Neurosurgery in large, partially remote catchment areas. We therefore analysed the chronology and transport logistics of aSAH patients in the South-Eastern Norway Health Region and related them to the frequency of aneurysm rebleed and 1-year mortality. METHODS Retrospective analysis of aSAH patients bleeding within our region admitted to Neurosurgery during a 5-year period. Date, time and site of ictus and arrival at Neurosurgery, distance and mode of transport and admission were obtained from our institutional quality register and the emergency medical communication centre log. We scored the patients' clinical condition, rebleeds and 1-year mortality. RESULTS Five hundred forty-four patients were included. Median time from ictus to arrival Neurosurgery was 4.5 h. Transport by road ambulance was most common at distances between the ictus scene and Neurosurgery below 50 km, whereas airborne transport became increasingly more common at larger distances. Direct admissions, frequency of intubation and airborne transport to Neurosurgery increased with the severity of haemorrhage, leading to shorter transport times. The risk of rebleed was 0.8%/hour of transport. The rebleed rate was independent of distances travelled, but increased with the severity of aSAH, reaching up to 6.54%/hour in poor-grade patients. Distance and time of transport had no impact on 1-year mortality, whereas poor-grade aSAH and rebleed were strong predictors of mortality. CONCLUSIONS Poor-grade aSAH patients have a high risk of rebleed independent of the distance between the ictus scene and Neurosurgery. As rebleeding triples 1-year mortality, patients with Glasgow Coma Score < 9 with suspected aSAH should be admitted directly to Neurosurgery without delay after best possible cardiovascular and airway optimisation on site by competent personnel.
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Abstract
Central nervous system hemorrhage has multiple pathophysiologic etiologies, including intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI). Given the nuances intrinsic to each of these etiologies and pathophysiologic processes, optimal blood pressure varies significantly and depends on type of hemorrhage and individual characteristics. This article reviews the most current evidence regarding blood pressure targets and provides guidance on reversal of anticoagulation for TBI, ICH, and SAH. It also describes the assessment, optimal therapeutic targets, and interventions to treat intracranial hypertension that can result from TBI, ICH, or SAH.
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Affiliation(s)
- Evie Marcolini
- Department of Surgery, Division of Emergency Medicine, University of Vermont College of Medicine, 111 Colchester Avenue, Burlington, VT 05401, USA; Department of Neurology, Division of Neurocritical Care, University of Vermont College of Medicine, 111 Colchester Avenue, Burlington, VT 05401, USA.
| | - Christoph Stretz
- Division of Vascular Neurology, Yale School of Medicine, 15 York Street, LLCI Building Suite 1004, New Haven, CT 06510, USA
| | - Kyle M DeWitt
- Department of Pharmacy, The University of Vermont Medical Center, 111 Colchester Avenue, Mailstop 272 BA1, Burlington, VT 05401, USA
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Der-Nigoghossian C, Levasseur-Franklin K, Makii J. Acute Blood Pressure Management in Neurocritically Ill Patients. Pharmacotherapy 2019; 39:335-345. [PMID: 30734342 DOI: 10.1002/phar.2233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Optimal blood pressure (BP) management is controversial in neurocritically ill patients due to conflicting concerns of worsening ischemia with decreased BP versus cerebral edema and increased intracranial pressure with elevated BP. In addition, high-quality evidence is lacking regarding optimal BP goals in patients with most of these conditions. This review summarizes guideline recommendations and examines the literature for BP management in patients with ischemic stroke, intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, and spinal cord injury.
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Affiliation(s)
| | | | - Jason Makii
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Francoeur CL, Roh D, Schmidt JM, Mayer SA, Falo MC, Agarwal S, Connolly ES, Claassen J, Elkind MS, Park S. Desmopressin administration and rebleeding in subarachnoid hemorrhage: analysis of an observational prospective database. J Neurosurg 2019; 130:502-508. [PMID: 29393750 PMCID: PMC6688966 DOI: 10.3171/2017.7.jns17990] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/14/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Rebleeding remains a frequent and catastrophic event leading to poor outcome after subarachnoid hemorrhage (SAH). Reduced platelet function after the initial bleed is associated with higher risk of early rebleeding. Desmopressin (DDAVP) is a well-known hemostatic agent, and recent guidelines already suggest its use in individuals exposed to antiplatelet drugs. The authors hypothesized that DDAVP administration in patients with SAH at admission would be associated with lower risks of rebleeding. METHODS The authors performed an observational cohort study of patients enrolled in the Columbia University SAH Outcome Project between August 1996 and July 2015. The authors compared the rate of rebleeding between patients who were and those who were not treated with DDAVP. After adjustment for known predictors, logistic regression was used to measure the association between treatment with DDAVP and risks of rebleeding. RESULTS Among 1639 patients with SAH, 12% were treated with DDAVP. The main indication for treatment was suspected exposure to an antiplatelet agent. The overall incidence of rebleeding was 9% (1% among patients treated with DDAVP compared with 8% among those not treated). After adjustment for antiplatelet use and known predictors, treatment with DDAVP was associated with a 45% reduction in the risks of rebleeding (adjusted OR 0.55, 95% CI 0.27-0.97). DDAVP was associated with a higher incidence of hyponatremia but not with thrombotic events or delayed cerebral ischemia. CONCLUSIONS Treatment with DDAVP was associated with a lower risk of rebleeding among patients with SAH. These findings support further study of DDAVP as first-line therapy for medical hemostasis in patients with SAH.
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Affiliation(s)
- Charles L. Francoeur
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Université Laval, Québec, Québec, Canada; Department of Critical Care, CHU de Québec—Université Laval, 1401 18e rue Québec, Québec G1J 1Z4, Canada
| | - David Roh
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - J. Michael Schmidt
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Stephan A. Mayer
- Department of Neurology, Neuroscience Institute, Henry Ford Health System, 2799 W. Grand Blvd, Detroit MI 48202
| | - M. Cristina Falo
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Sachin Agarwal
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - E. Sander Connolly
- Department of Neurosurgery, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States, United States
| | - Jan Claassen
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Mitchell S Elkind
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Soojin Park
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
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Waldron JR, Crockett M, Phillips T. Hyperacute intracranial aneurysm rebleed captured on planar and 3D digital subtraction angiography. Radiol Case Rep 2018; 13:1012-1017. [PMID: 30228834 PMCID: PMC6137340 DOI: 10.1016/j.radcr.2018.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/01/2018] [Indexed: 11/23/2022] Open
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Maagaard M, Karlsson WK, Ovesen C, Gluud C, Jakobsen JC. Interventions for altering blood pressure in people with acute subarachnoid haemorrhage. Hippokratia 2018. [DOI: 10.1002/14651858.cd013096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Mathias Maagaard
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - William K Karlsson
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
- Herlev Hospital; Department of Neurology; Herlev Ringvej 75 Copenhagen Denmark 2730
| | - Christian Ovesen
- Bispebjerg Hospital, University of Copenhagen; Department of Neurology; Bispebjerg Bakke 23 Copenhagen NV Denmark 2400
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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Comparison of Aggressive Surgical Treatment and Palliative Treatment in Elderly Patients with Poor-Grade Intracranial Aneurysmal Subarachnoid Hemorrhage. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5818937. [PMID: 29998135 PMCID: PMC5994574 DOI: 10.1155/2018/5818937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/19/2018] [Indexed: 12/29/2022]
Abstract
Objective To compare the current treatment approach in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) and identify the independent predictors of the outcome after aggressive surgical treatment. Method This prospective, multicenter cohort study included 104 poor-grade aneurysmal SAH elderly patients, 60 years or older, treated in our institution from October 2010 to March 2013. Patients were grouped according to three treatment arms. Neurological outcome was assessed using the Glasgow Outcome Scale (GOS) at baseline and at a 12-month follow-up. Univariate and multivariate analysis were performed using the following factors: sex, age, smoking history, breathing ability, alcohol consumption, cerebral hernia, aneurysm location, aneurysm diameter, WFNS grade, CT Fisher grade, treatment approach, and the timing of the aneurysm surgery. Results At the 12-month follow-up, patients in the coiling group and clipping group had better prognosis than patients in the palliative treatment group. Univariate analysis confirmed that the treatment approach, WFNS grade, CT Fisher grade, and age are critical factors for neurological outcomes in poor-grade SAH. Multivariate analysis indicated that WFNS grade V, CT Fisher grades 3-5, and palliative treatment were independent predictors of poor prognoses. Conclusion Aggressive surgical treatment improves the prognoses in poor-grade aneurysm elderly patients with SAH. Elderly Patients of WFNS grade IV and CT Fisher grades 1-2 are more likely to have a better outcome.
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Chee LC, Siregar JA, Ghani ARI, Idris Z, Rahman Mohd NAA. The Factors Associated with Outcomes in Surgically Managed Ruptured Cerebral Aneurysm. Malays J Med Sci 2018; 25:32-41. [PMID: 29599633 DOI: 10.21315/mjms2018.25.1.5] [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: 05/19/2017] [Accepted: 10/25/2017] [Indexed: 10/17/2022] Open
Abstract
Background Ruptured cerebral aneurysm is a life-threatening condition that requires urgent medical attention. In Malaysia, a prospective study by the Umum Sarawak Hospital, Neurosurgical Center, in the year 2000-2002 revealed an average of two cases of intracranial aneurysms per month with an operative mortality of 20% and management mortality of 25%. Failure to diagnose, delay in admission to a neurosurgical centre, and lack of facilities could have led to the poor surgical outcome in these patients. The purpose of this study is to identify the factors that significantly predict the outcome of patients undergoing a surgical clipping of ruptured aneurysm in the local population. Material and Method A single center retrospective study with a review of medical records was performed involving 105 patients, who were surgically treated for ruptured intracranial aneurysms in the Sultanah Aminah Hospital, in Johor Bahru, from July 2011 to January 2016. Information collected was the patient demographic data, Glasgow Coma Scale (GCS) prior to surgery, World Federation of Neurosurgical Societies Scale (WFNS), subarachnoid hemorrhage (SAH) grading system, and timing between SAH ictus and surgery. A good clinical grade was defined as WFNS grade I-III, whereas, WFNS grades IV and V were considered to be poor grades. The outcomes at discharge and six months post surgery were assessed using the modified Rankin's Scale (mRS). The mRS scores of 0 to 2 were grouped into the "favourable" category and mRS scores of 3 to 6 were grouped into the "unfavourable" category. Only cases of proven ruptured aneurysmal SAH involving anterior circulation that underwent surgical clipping were included in the study. The data collected was analysed using the Statistical Package for Social Sciences (SPSS). Univariate and multivariate analyses were performed and a P-value of < 0.05 was considered to be statistically significant. Result A total of 105 patients were included. The group was comprised of 42.9% male and 57.1% female patients. The mean GCS of the patients subjected to surgical clipping was 13, with the majority falling into the good clinical grade (78.1%). The mean timing of the surgery after SAH was 5.3 days and this was further categorised into early (day one to day three, 45.3%), intermediate (day four to day ten, 56.2%), and late (after day ten, 9.5%). The total favourable outcome achieved at discharge was 59.0% as compared to 41.0% of the unfavourable outcome, with an overall mortality rate of 10.5%. At the six-month post surgery review (n = 94), the patients with a favourable outcome constituted 71.3% as compared to 28.7% with an unfavourable outcome. The mortality, six months post surgery was 3.2%. On a univariate analysis of early surgical clipping, patients with a better GCS and good clinical grade had a significantly better outcome at discharge. Based on the univariate study, six months post surgery, the timing of the surgery and the clinical grade remained significant predictors of the outcome. On the basis of the multivariate analysis, male patients of younger age, with a good clinical grade, were associated with favourable outcomes, both at discharge and six months post surgery. Conclusion In this study, we concluded that younger male patients with a good clinical grade were associated with a favourable outcome both at discharge and six months post surgery. We did not find the timing of the surgery, size of the aneurysm or duration of surgery to be associated with a patient's surgical outcome. Increasing age was not associated with the surgical outcome in a longer term of patient's follow up.
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Affiliation(s)
- Lai Chuang Chee
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.,Department of Neurosurgery, Hospital Sultanah Aminah, 80100 Johor Bahru, Johor, Malaysia
| | - Johari Adnan Siregar
- Department of Neurosurgery, Hospital Kuala Lumpur, 50586 Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Abdul Rahman Izani Ghani
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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Maldaner N, Burkhardt JK, Stienen MN, Goldberg J, Bervini D, Bijlenga P, Croci D, Zumofen D, D’Alonzo D, Marbacher S, Maduri R, Daniel RT, Serra C, Esposito G, Neidert MC, Bozinov O, Regli L. Decision-making and neurosurgeons' agreement in the management of aneurysmal subarachnoid haemorrhage based on computed tomography angiography. Acta Neurochir (Wien) 2018; 160:253-260. [PMID: 29214402 DOI: 10.1007/s00701-017-3415-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 11/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine the neurosurgeon's agreement in aneurysmal subarachnoid haemorrhage (aSAH) management with special emphasis on the rater's level of experience. A secondary aim was to analyse potential aneurysm variables associated with the therapeutic recommendation. METHOD Basic clinical information and admission computed tomography angiography (CTA) images of 30 consecutive aSAH patients were provided. Twelve neurosurgeons independently evaluated aneurysm characteristics and gave recommendations regarding the emergency management and aneurysm occlusion therapy. Inter-rater variability and predictors of treatment recommendation were evaluated. RESULTS There was an overall moderate agreement in treatment decision [κ = 0.43; 95% confidence interval ((CI), 0.387-0.474] with moderate agreement for surgical (κ = 0.43; 95% CI, 0.386-0.479) and endovascular treatment recommendation (κ = 0.45; 95% CI, 0.398-0.49). Agreement on detailed treatment recommendations including clip, coil, bypass, stent, flow diverter and ventriculostomy was low to moderate. Inter-rater agreement did not significantly differ between residents and consultants. Middle cerebral artery (MCA) aneurysm location was a positive predictor of surgical treatment [odds ratio (OR), 49.57; 95% CI, 10.416-235.865; p < 0.001], while patients aged >65 years (OR, 0.12; 95% CI, 0.03-0.0434; p = 0.001), fusiform aneurysm type (OR, 0.18; 95% CI, 0.044-0.747; p = 0.018) and intracerebral haematoma (ICA) aneurysm location (OR, 0.24; 95% CI, 0.088-0.643; p = 0.005) were associated with a recommendation for endovascular treatment. CONCLUSIONS Agreement on aSAH management varies considerably across neurosurgeons, while therapeutic decision-making is challenging on an individual patient level. However, patients aged >65 years, fusiform aneurysm shape and ICA location were associated with endovascular treatment recommendation, while MCA aneurysm location remains a surgical domain in the opinion of neurosurgeons without formal endovascular training.
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Galea JP, Dulhanty L, Patel HC. Predictors of Outcome in Aneurysmal Subarachnoid Hemorrhage Patients. Stroke 2017; 48:2958-2963. [DOI: 10.1161/strokeaha.117.017777] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/24/2017] [Accepted: 08/28/2017] [Indexed: 11/16/2022]
Affiliation(s)
- James P. Galea
- From the Vascular and Stroke Center, Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Center, University of Manchester, United Kingdom (J.P.G., H.C.P.); Greater Manchester Neurosciences Center, Salford Royal Foundation NHS Trust, United Kingdom (L.D., H.C.P.); and Ninewells Hospital and Medical School, Ninewells, Dundee, United Kingdom (J.P.G.)
| | - Louise Dulhanty
- From the Vascular and Stroke Center, Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Center, University of Manchester, United Kingdom (J.P.G., H.C.P.); Greater Manchester Neurosciences Center, Salford Royal Foundation NHS Trust, United Kingdom (L.D., H.C.P.); and Ninewells Hospital and Medical School, Ninewells, Dundee, United Kingdom (J.P.G.)
| | - Hiren C. Patel
- From the Vascular and Stroke Center, Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Center, University of Manchester, United Kingdom (J.P.G., H.C.P.); Greater Manchester Neurosciences Center, Salford Royal Foundation NHS Trust, United Kingdom (L.D., H.C.P.); and Ninewells Hospital and Medical School, Ninewells, Dundee, United Kingdom (J.P.G.)
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Abstract
Although commonly arising from poorly controlled hypertension, spontaneous intracerebral hemorrhage may occur secondary to several other etiologies. Clinical presentation to the emergency department ranges from headache with vomiting to coma. In addition to managing the ABCs, the crux of emergency management lies in stopping hematoma expansion and other complications to prevent clinical deterioration. This may be achieved primarily through anticoagulation reversal, blood pressure, empiric management of intracranial pressure, and early neurosurgical consultation for posterior fossa hemorrhage. Patients must be admitted to intensive care. The effects of intracerebral hemorrhage are potentially devastating with very poor prognoses for functional outcome and mortality.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.
| | - Cappi Lay
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA; Department of Neurocritical Care, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
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Shotar E, Pistocchi S, Haffaf I, Bartolini B, Jacquens A, Nouet A, Chiras J, Degos V, Sourour NA, Clarençon F. Early Rebleeding after Brain Arteriovenous Malformation Rupture, Clinical Impact and Predictive Factors: A Monocentric Retrospective Cohort Study. Cerebrovasc Dis 2017; 44:304-312. [DOI: 10.1159/000479120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 06/30/2017] [Indexed: 11/19/2022] Open
Abstract
Background: Brain arteriovenous malformations (BAVMs) are a leading cause of intracranial hemorrhage in young adults. This study aimed to identify individual predictive factors of early rebleeding after BAVM rupture and determine its impact on prognosis. Methods: Early rebleeding was defined as a spontaneous intracranial hemorrhage within 30 days of BAVM rupture in patients with nonobliterated BAVMs. One hundred fifty one patients with 158 BAVM hemorrhagic events admitted to a tertiary care center during 14 years were included. Univariate followed by multivariate logistic regression was performed to assess the impact of early rebleeding on in-hospital mortality and modified Rankin Scale (mRS) score beyond 3 months and to identify independent predictors of early rebleeding. Results: Eight early rebleeding events were observed, 6 of which occurred during the first 7 days. Early rebleeding was independently and significantly associated with poor outcome (mRS ≥3 beyond 3 months, p = 0.004) but not with in-hospital mortality (p = 0.9). Distal flow-related aneurysms (p = 0.009) and altered consciousness with a Glasgow coma scale score of 3 (p = 0.01) were independently associated with early rebleeding. Conclusions: Early rebleeding is a severe complication that can occur after BAVM-related hemorrhage. Distal flow-related aneurysms and initial altered consciousness are associated with early rebleeding.
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Treatment of Large and Giant Middle Cerebral Artery Aneurysms: Risk Factors for Unfavorable Outcomes. World Neurosurg 2017; 102:301-312. [PMID: 28323182 DOI: 10.1016/j.wneu.2017.03.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study aimed to assess the clinical and radiologic outcomes after neurosurgical treatment of large and giant aneurysms of the middle cerebral artery (MCA). In addition, we aimed to identify risk factors for unfavorable outcomes. METHODS This retrospective study included 105 patients with 106 large or giant MCA aneurysms treated with neurosurgical methods, including microsurgery and endovascular treatment, over a 15-year period. RESULTS The mean aneurysm size was 15.3 ± 7.1 mm. Ten (9.4%) were giant aneurysms. The MCA bifurcation was the most common aneurysm site, followed by the MCA trunk and distal MCA. Aneurysm clipping was the most common treatment method, followed by clipping or trapping with bypass surgery and endovascular treatment. However, acute cerebral infarction was the most common complication (16.0%), poor outcomes (modified Rankin Scale score, 3-6) developed in 12.3% of aneurysms after treatment, and 6.6% of treated aneurysms needed retreatment. Multivariate analysis showed that independent risk factors for acute cerebral infarction after treatment were aneurysms located on the MCA trunk and 2 or more underlying diseases. Initial presentation with subarachnoid hemorrhage and complications during treatment were independent risk factors for poor outcomes. In addition, endosaccular coiling was an independent risk factor for retreatment. CONCLUSIONS Neurosurgical management should be considered a priority for large and giant MCA aneurysms because of the high rupture rate and clinical symptoms. However, treatment outcomes remain unsatisfactory. Therefore, tailored management with consideration of risk factors for unfavorable outcomes should be implemented.
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Zhao B, fan Y, Xiong Y, Yin R, Zheng K, Li Z, Tan X, Yang H, Zhong M. Aneurysm rebleeding after poor-grade aneurysmal subarachnoid hemorrhage: Predictors and impact on clinical outcomes. J Neurol Sci 2016; 371:62-66. [DOI: 10.1016/j.jns.2016.10.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 10/03/2016] [Accepted: 10/13/2016] [Indexed: 12/27/2022]
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Abstract
PURPOSE OF REVIEW Outcome of patients with aneurysmal subarachnoid haemorrhage (ASAH) has improved, but is still poor. After the introduction of endovascular treatment of intracranial aneurysms, much attention has been given to indications for and advances in endovascular and microneurosurgical techniques to occlude aneurysms, but management of patients with ASAH encompasses much more than occluding the aneurysm. RECENT FINDINGS This review describes recent advances in diagnosis and general management of ASAH and in knowledge and medical treatment of delayed cerebral ischaemia and rebleeding. SUMMARY In patients with a head computed tomography scan performed less than 6 h after headache onset and reported negative by a staff radiologist, lumbar puncture can be withheld. Patients with ASAH should preferably be treated in a tertiary care centre that treats more than 100 ASAH patients per year. Currently, the only treatment strategy to reduce the risk of delayed cerebral ischaemia remains nimodipine; there is no place for statins or magnesium sulphate, nor for lumbar drainage. Hypervolaemia and induced hypertension may be less beneficial than presumed, and further trials are urgently needed. Very early and short treatment with antifibrinolytic drugs may also be beneficial, but data from ongoing trials should be awaited before this treatment strategy can be implemented.
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Abstract
PURPOSE OF REVIEW The purpose of this article is to present the epidemiology, clinical presentation, and management of patients with subarachnoid hemorrhage (SAH). SAH is a neurologic emergency that carries high morbidity and mortality. Patients with SAH are at risk for several significant neurologic complications, including hydrocephalus, cerebral edema, delayed cerebral ischemia, rebleeding, seizures, and neuroendocrine abnormalities that lead to impaired body regulation of sodium, water, and glucose. RECENT FINDINGS The incidence of SAH has remained stable, but mortality of hospitalized patients has significantly declined over the past 3 decades. Many common therapies for SAH have created controversy, and various recent neuroprotective clinical trials have produced negative results. However, the publication of two consensus guidelines by the American Heart Association/American Stroke Association and the Neurocritical Care Society have provided a clarification for what should constitute best practice for patients with SAH. The most important of those recommendations include the following: admission of patients to high-volume centers (defined as more than 35 patients with SAH per year) under the management of a specialized and multidisciplinary team; early identification and management of the bleeding source; evaluation and treatment decision for unsecured aneurysms by a multidisciplinary team made up of cerebrovascular neurosurgeons, endovascular practitioners, and neurointensivists; management of patients in the neurocritical care unit with oral nimodipine, blood pressure control, euvolemia, and frequent monitoring for neurologic and systemic complications; and delayed cerebral ischemia secondary to cerebral vasospasm should be treated with induced hypertension and endovascular therapies once confirmed. SUMMARY SAH is a devastating neurologic disease. Management of patients with SAH should adhere to currently available treatment guidelines. Several aspects of SAH management remain controversial and need further studies to clarify their role in improving patient outcome.
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Predictors of good functional outcomes and mortality in patients with severe rebleeding after aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2016; 144:28-32. [PMID: 26963087 DOI: 10.1016/j.clineuro.2016.02.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/28/2016] [Accepted: 02/29/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Aneurysmal rebleeding is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH); however, limited data on severity of rebleeding and outcomes after severe rebleeding are available. We aimed to determine predictors of good outcome and mortality after severe rebleeding. MATERIALS AND METHODS In a multicenter poor-grade aneurysm study, 60 patients with severe rebleeding, defined as new hemorrhage with poor clinical condition caused by rebleeding, were identified. Good functional outcome was defined as a modified Rankin scale (mRS) of ≤2, and mortality was defined as a mRS of 6. Multivariate logistic analyses were used to determine predictors of good outcome and mortality. RESULTS Of the 58 patients included in this report, 24 (41.3%) patients experienced rebleeding within 24h after ictus. 42 (72.4%) patients had died at 12 months. The rate of good outcome increased from 5.2% at discharge to 13.8% at 6 months and 19.0% at 12 months. In multivariate analysis, World Federation of Neurosurgical Societies (WFNS) grade IV after rebleeding (P=0.007) and aggressive treatment (P=0.039) were independently associated with good outcome. A higher modified Fisher grade before rebledding (P=0.040), larger aneurysms (P=0.005), and lower Glasgow coma score after rebleeding (P=0.003) were independently associated with increased mortality. CONCLUSIONS A better clinical condition after rebleeding were independently associated with good outcome and inversely associated with morality after severe rebleeding. Despite high mortality of rebleeding, patients with WFNS grade IV treated with aggressive treatment were more likely to have good outcomes regardless of their condition before rebleeding.
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Lin QS, Ping-Chen, Lin YX, Lin ZY, Yu LH, Dai LS, Kang DZ. Systolic Blood Pressure Variability is a Novel Risk Factor for Rebleeding in Acute Subarachnoid Hemorrhage: A Case-Control Study. Medicine (Baltimore) 2016; 95:e3028. [PMID: 26986118 PMCID: PMC4839899 DOI: 10.1097/md.0000000000003028] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
UNLABELLED Rebleeding of an aneurysm is a major cause of morbidity and mortality after subarachnoid hemorrhage (SAH). Whereas numerous studies have demonstrated predictors of rebleeding and effect of systolic blood pressure variability (SBPV) on stroke, few data on the association between SBPV and rebleeding. Here, we sought to identify the effect of SBPV on rebleeding in acute aneurysmal SAH. Case-control study. From January 2010 to June 2015, 612 patients with aneurysmal SAH were enrolled in our tertiary care medical center. MAIN OUTCOME MEASURES Consecutive patients with acute (<3 days from ictus) aneurismal rebleeding or repair or death were retrospectively included. Antihypertensive therapy based on a predefined standardized protocol was prescribed to lower and maintain SBP between 120 and 160 mm Hg. SBP was measured hourly until a censoring event occurred. SBPV was determined as standard deviation (SD) and successive variation (SV). Binary logistic regression was used to assess the association between SBPV and rebleeding. Rebleeding occurred in 61 (10.0%) of the 612 patients. We identified 47 acute rebleeding as cases and 382 early repair or early death as controls. On binary logistic regression analysis, rebleeding was associated with the SD of SBP (odds ratio [OR], 1.254; 95% confidence interval [CI], 1.131-1.391; P < 0.001) and the SV of SBP (OR, 1.131; 95% CI, 1.039-1.231; P = 0.004). No significant difference was seen between rebleeding and mean systolic blood pressure (MSBP). SBPV is associated with increased rates of acute aneurysmal rebleeding. Further prospective research is warranted to confirm that SBP stability prevents acute aneurysm rebleeding.
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Affiliation(s)
- Qing-Song Lin
- From the Department of Neurosurgery (Q-SL, Y-XL, Z-YL, L-HY, L-SD); and Department of Anesthesiology, the First Affiliated Hospital of Fujian Medical University (P-C), Fuzhou, Fujian, People's Republic of China
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Carcel C, Sato S, Anderson CS. Blood Pressure Management in Intracranial Hemorrhage: Current Challenges and Opportunities. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:22. [PMID: 26909816 DOI: 10.1007/s11936-016-0444-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OPINION STATEMENT Non-traumatic intracranial hemorrhage (i.e. intracerebral hemorrhage [ICH] and subarachnoid hemorrhage [SAH]) are more life threatening and least treatable despite being less common than ischemic stroke. Elevated blood pressure (BP) is a strong predictor of poor outcome in both ICH and SAH. Data from a landmark clinical trial INTERACT 2, wherein 2839 participants enrolled with spontaneous ICH were randomly assigned to receive intensive (target systolic BP <140 mmHg) or guideline recommended BP lowering therapy (target systolic BP <180 mmHg), showed that intensive BP lowering was safe, and more favorable functional outcome and better overall health-related quality of life were seen in survivors in the intensive treatment group. These results contributed to the shift in European and American guidelines towards more aggressive early management of elevated BP in ICH. In contrast, the treatment of BP in SAH is less well defined and more complex. Although there is consensus that hypertension needs to be controlled to prevent rebleeding in the acute setting, induced hypertension in the later stages of SAH has questionable benefits.
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Affiliation(s)
- Cheryl Carcel
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Neurology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Shoichiro Sato
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Craig S Anderson
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia. .,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia. .,Neurology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. .,The George Institute for Global Health, PO Box M201, Missenden Road, Sydney, NSW, 2050, Australia.
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Oheda M, Inamasu J, Moriya S, Kumai T, Kawazoe Y, Nakae S, Kato Y, Hirose Y. Early rebleeding in patients with subarachnoid haemorrhage under intensive blood pressure management. J Clin Neurosci 2015; 22:1338-42. [DOI: 10.1016/j.jocn.2015.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/16/2015] [Accepted: 02/14/2015] [Indexed: 10/23/2022]
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Yin C, Huang GF, Ruan J, He ZZ, Sun XC. The APOE promoter polymorphism is associated with rebleeding after spontaneous SAH in a Chinese population. Gene 2015; 563:52-5. [PMID: 25752291 DOI: 10.1016/j.gene.2015.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/09/2015] [Accepted: 03/04/2015] [Indexed: 12/30/2022]
Affiliation(s)
- Cheng Yin
- Department of Neurosurgery, Hospital of the University of Electronic Science and Technology of China, Sichuan Provincial People's Hospital, Chengdu 610072, PR China
| | - Guang-fu Huang
- Department of Neurosurgery, Hospital of the University of Electronic Science and Technology of China, Sichuan Provincial People's Hospital, Chengdu 610072, PR China
| | - Jian Ruan
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Zong-ze He
- Department of Neurosurgery, Hospital of the University of Electronic Science and Technology of China, Sichuan Provincial People's Hospital, Chengdu 610072, PR China
| | - Xiao-chuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China.
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Predictor's of Mortality in Patients with Aneurysmal Subarachnoid Haemorrhage and Reebleding. Neurol Res Int 2015; 2015:545407. [PMID: 25722889 PMCID: PMC4334863 DOI: 10.1155/2015/545407] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 01/17/2015] [Indexed: 11/17/2022] Open
Abstract
Methods. “Ameijeiras Brother's” and “Cmdt. Manuel Fajardo” Hospitals enrolled 64 patients (multicentre retrospective cohort) with aneurysmal subarachnoid haemorrhage and rebleeding. The patients were admitted to the Stroke Unit (SU) between January 1, 2006, and December 1, 2013. Demographic, clinical, and radiological variables were examined in logistic regression to evaluate independent factors for increasing the risk of death. Results. Patients with systolic blood pressure >160 mmHg (P = 0.02), serum glucose >7 mmol/L (P = 0.02), aneurysm location in artery communicant anterior (P = 0.03), and black/mixed race (P = 0.008) were significant related to death in univariate analysis. Risk factors (HTA, smoke, alcohol consumption, and DM), complication, multiplex rebleeding and stage of WFNS, and Fisher's scale were not related to mortality. Patients with three or more complications had a higher mortality rate (P = 0.002). The results of the multivariate logistic regression analysis indicated that race (black/mixed, P = 0.00, OR 4.62, and 95% IC 1.40–16.26), systolic blood pressure (>160 mmHg, P = 0.05, OR 2.54, and 95% IC 1.01–3.13), and serum glucose (>7.0 mmol/L, P = 0.05, OR 1.82, and 95% IC 1.27–2.67) were independent risk factors for death. Conclusions. The black/mixed race, SBP, and serum glucose were independent predictors of mortality. Three or more complications were associated with increasing the probability to death. Further investigation is necessary to validate these findings.
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