Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management

Recognizing the signs and symptoms of aneurysmal subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is a devastating neurologic condition with a high mortality and long term neurological morbidity in 50% of survivors. In addition, SAH commonly affects young patients causing substantial loss of productive life years and resulting in significant long term healthcare costs. Early recognition of the signs and symptoms of SAH is absolutely critical to earlier intervention, and delays in diagnosis can have devastating consequences. To avoid such delays in SAH diagnosis, the medical provider should recognize its signs and symptoms. Neuroimgaging, cerebrospinal fluid examination and angiography (invasive or non-invasive) facilitate early diagnosis of SAH. The purpose of this review is not to provide an exhaustive critique of the available literature, rather, it is to provide an overview that will better enable a provider to recognize and initiate the workup of patients with SAH.

Perioperative hypertensive emergencies

The concept of "perioperative hypertensive emergency" must be defined differently from that of ambulatory hypertensive emergency in view of its unique clinical considerations in an atypical setting. It should be noted that moderately high normal blood pressure (BP) values in the perioperative setting often trigger situations requiring immediate treatment in what would otherwise be a "BP-acceptable" non-surgical condition. Commonly recognized circumstances that may result in a perioperative hypertensive emergency include exacerbation of severe mitral insufficiency, hypertension resulting in acute decompensated heart failure, hypertension caused by acute catecholamine excess, rebound hypertension after withdrawal of antihypertensive medications, hypertension resulting in bleeding from vascular surgery suture lines, intracerebral hemorrhage, aortic dissection, hypertension associated with preeclampsia, and hypertension associated with autonomic dysreflexia. In addition, perioperative BP lability has been reported to increase the risk for stroke, acute kidney injury, and 30-day mortality in patients undergoing cardiac surgery.

Transfer time to a high-volume center for patients with subarachnoid hemorrhage does not affect outcomes

OBJECTIVES

The objective of our study was to examine patients with aneurysmal subarachnoid hemorrhage transferred and directly admitted to our institution in order to determine how transfer time affects outcomes.

METHODS

A retrospective cohort study was performed of all patients undergoing treatment for aneurysmal subarachnoid hemorrhage between 2005 and 2012 at the University of Michigan. Variables, including transfer time, were tested for their independent association with the primary outcomes of symptomatic vasospasm and 12-month outcome as well as secondary outcomes of aneurysm rebleeding and 12-month mortality.

RESULTS

During the study period, 263 (87.4%) patients were transferred to our institution and 38 (12.6%) were directly admitted for treatment of aneurysmal subarachnoid hemorrhage. Transfer time was not associated with the occurrence of symptomatic vasospasm, 12-month outcome, rebleeding, or 12-month mortality. Higher Hunt-Hess grade was associated with the occurrence of symptomatic vasospasm as well as with poorer 12-month outcome.

CONCLUSIONS

Transfer time was not associated with the occurrence of symptomatic vasospasm, 12-month outcome, rebleeding, or 12-month mortality. We believe our data argue that protocols should emphasize early resuscitation and stabilization followed by safe transfer rather than a hyperacute transfer paradigm. However, transfer time should be minimized as much as possible so as not to delay time to definitive treatment.

Suboptimal interventional conditions for the occlusion of ruptured intracranial aneurysms do not increase periprocedural complications and poor clinical outcomes

BACKGROUND AND OBJECTIVE

Occluding a ruptured intracranial aneurysm as early as possible may entail certain periprocedural conditions that compromise the outcome. The aim of the present study was to evaluate the effectiveness, safety, and clinical outcome of endovascular coiling procedures performed on an emergency basis under potentially suboptimal conditions, and to compare results with those from scheduled procedures under potentially optimal conditions.

METHODS

Interventions performed on 66 SAH patients were retrospectively analysed by classifying them into two groups: under emergency (within three hours from diagnosis or during non-standard working hours) or scheduled conditions. A binary logistic regression analysis was also performed to identify characteristics associated with poor outcomes.

RESULTS

No differences in effectiveness, periprocedural complications, or clinical outcomes were found between the two groups. Rebleeding was detected in 4.8 % of the emergency interventions and 2.2 % of the scheduled interventions. Multivariate analysis identified age and Hunt and Hess grade, but no conditions of treatment, as the factors associated to poor outcome.

CONCLUSION

Suboptimal interventional conditions for occluding ruptured intracranial aneurysms, such as performing procedures outside of standard working hours or within three hours of diagnosis, do not result in increased periprocedural complications and poor clinical outcomes compared with scheduled procedures under potentially optimal conditions. These results suggest the need for treatment to be provided as soon as possible.

Rupturing Anterior Communicating Artery Aneurysm during Computed Tomography Angiography: Three-Dimensional Visualization of Bleeding into the Septum Pellucidum and the Lateral Ventricle

Computed tomography angiography (CTA) is commonly used in setting of subarachnoid hemorrhage, but imaging features of aneurysm rupturing taking place at the time of scanning has rarely been described. The author reports a case of actively rebleeding aneurysm of the anterior communicating artery with intraventricular extravasation on the hyperacute CTA imaging. The rebleeding route, not into the third ventricle but into the lateral ventricles, can be visualized by real-time three-dimensional CT pictures. The hemorrhage broke the septum pellucidum and the lamina rostralis rather than the lamina terminalis.

Risk factors for rebleeding of aneurysmal subarachnoid hemorrhage: a meta-analysis

Background

Rebleeding is a serious complication of aneurysmal subarachnoid hemorrhaging. To date, there are conflicting data regarding the factors contributing to rebleeding and their significance.

Methods

A systematic review of PubMed and Embase databases was conducted for studies pertaining to aneurysmal subarachnoid hemorrhage (aSAH) and rebleeding in order to assess the associated risk factors. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated from fourteen studies comprised of a total of 5693 patients that met the inclusion criteria.

Results

Higher rebleeding rates were observed < 6 h after the initial aSAH (OR  = 3.22, 95% CI  = 1.46–7.12), and were associated with high systolic blood pressure (OR  = 1.93, 95% CI  = 1.31–2.83), poor Hunt-Hess grade (III–IV) (OR  = 3.43, 95% CI  = 2.33–5.05), intracerebral or intraventricular hematomas (OR  = 1.65, 95% CI  = 1.33–2.05), posterior circulation aneurysms (OR  = 2.15, 95% CI  = 1.32–3.49), and aneurysms >10 mm in size (OR  = 1.70, 95% CI  = 1.35–2.14).

Conclusions

Aneurysmal rebleeding occurs more frequently within the first 6 hours after the initial aSAH. Risk factors associated with rebleeding include high systolic pressure, the presence of an intracerebral or intraventricular hematoma, poor Hunt-Hess grade (III-IV), aneurysms in the posterior circulation, and an aneurysm >10 mm in size.

Comparison of Long-term Outcomes Associated With Endovascular Treatment vs Surgical Treatment Among Medicare Beneficiaries With Unruptured Intracranial Aneurysms

BACKGROUND:

Long-term outcomes associated with endovascular and surgical treatments for unruptured intracranial aneurysms are not well studied to date.

OBJECTIVE:

To determine the 5-year risk of new intracranial hemorrhage, second procedure, and all-cause mortality in elderly patients with unruptured intracranial aneurysms who underwent either surgical or endovascular treatment.

METHODS:

The study cohort included a representative sample of fee-for-service Medicare beneficiaries aged ≥65 years who underwent endovascular or surgical treatment for unruptured intracranial aneurysms with postprocedure follow-up of 4.7 (±3.0) years. Cox proportional hazards analysis was used to assess the relative risk (RR) of all-cause mortality, new intracranial hemorrhage, or second procedure for patients who underwent endovascular treatment compared with those who underwent surgical treatment after adjusting for potential confounders. The 5-year survival was estimated for both treatment groups by using Kaplan-Meier survival methods.

RESULTS:

A total of 688 patients with unruptured intracranial aneurysms were treated with either endovascular (n = 398) or surgical treatment (n = 290). The rate of immediate postprocedural neurological complications (10.3% vs 3.5%, P = .001) was higher among patients treated with surgery than among those who underwent endovascular treatment. The estimated 5-year survival was 92.8% and 94.8% in patients who underwent surgical and endovascular treatments, respectively. After adjusting for age, sex, and race/ethnicity, the RRs of all-cause mortality (RR, 0.6; 95% confidence interval, 0.3-1.1) and new intracranial hemorrhage (RR, 0.4; 95% confidence interval, 0.2-0.8) were lower with endovascular treatment.

CONCLUSION:

In elderly patients with unruptured intracranial aneurysms, endovascular treatment was associated with lower rates of acute adverse events and long-term all-cause mortality and new intracranial hemorrhages.

Controversies and evolving new mechanisms in subarachnoid hemorrhage

Despite decades of study, subarachnoid hemorrhage (SAH) continues to be a serious and significant health problem in the United States and worldwide. The mechanisms contributing to brain injury after SAH remain unclear. Traditionally, most in vivo research has heavily emphasized the basic mechanisms of SAH over the pathophysiological or morphological changes of delayed cerebral vasospasm after SAH. Unfortunately, the results of clinical trials based on this premise have mostly been disappointing, implicating some other pathophysiological factors, independent of vasospasm, as contributors to poor clinical outcomes. Delayed cerebral vasospasm is no longer the only culprit. In this review, we summarize recent data from both experimental and clinical studies of SAH and discuss the vast array of physiological dysfunctions following SAH that ultimately lead to cell death. Based on the progress in neurobiological understanding of SAH, the terms "early brain injury" and "delayed brain injury" are used according to the temporal progression of SAH-induced brain injury. Additionally, a new concept of the vasculo-neuronal-glia triad model for SAH study is highlighted and presents the challenges and opportunities of this model for future SAH applications.

A prospective evaluation of labetalol versus nicardipine for blood pressure management in patients with acute stroke

INTRODUCTION

Acute hypertension is common following stroke and contributes to poor outcomes. Labetalol and nicardipine are often used for acute hypertension but there are little data comparing the two. This study is to evaluate the therapeutic response and tolerability of these two agents following acute stroke.

METHODS

This is a prospective, pseudo-randomized study comparing labetalol and nicardipine for blood pressure (BP) management in acute stroke patients. Patients who presented to the emergency department (ED) with confirmed hemorrhagic or ischemic stroke received either labetalol or nicardipine for 24 h from ED admission. Therapeutic response was assessed by achievement of goal BP, time spent within goal, and variability in BP. Clinical outcomes including length of stay, clinical status at discharge, and in-hospital mortality were recorded.

RESULTS

54 patients were enrolled (labetalol = 28; nicardipine = 26) with 25 ± 6 BP measurements per patient. Majority of patients had a hemorrhagic stroke and baseline characteristics were similar between groups. All patients who received nicardipine achieved goal BP compared to 17 (61 %) in the labetalol group (p < 0.001) with 89 % nicardipine-treated patients achieved goal BP within 60 min of drug initiation versus 25 % in labetalol group (p < 0.001). Nicardipine group had better maintenance of BP, a greater percentage of time spent within goal, and significantly less BP variability compared to labetalol group (p < 0.001). Less rescue antihypertensive agents were given to nicardipine group than labetalol group (p < 0.001). The incidences of adverse drug events were similar between groups and there were no differences in clinical outcomes.

CONCLUSION

In acutely hypertensive stroke patients, superior therapeutic response was achieved with nicardipine versus labetalol. Despite this, there was no demonstrable difference in clinical outcomes.

Risk Factors for Re-bleeding of Aneurysmal Subarachnoid Hemorrhage: Systemic Review and Meta Analysis

Objective : The mortality of re-bleeding is high and patients surviving are usually in poor clinical condition and have a worse outcome than patients with single bleed. We performed an update systemic review and Meta-analysis to determine the most common risk factors for re-bleeding in aneurysmal subarachnoid hemorrhage patients.

Method: We reviewed all publications on the risk factors of the re-bleeding or rerupture of already bled intracranial aneurysms. This Meta analysis included studies published from the year 2000 until 2013. Pooled mean difference was calculated for the continuous variables (Age), and pooled odds ratio (OR) was calculated for categorical factors. Heterogeneity was tested first. If it is significant (p<0.05), random effect model was applied, otherwise, fixed model was used. Software - Review manager was used to find pooled effects and perform significant test for each potential risk factor.

Results : We identified 174 articles. Only 7 retrospective studies had met the inclusion criteria, with 2470 patients, 283 patients had aneurysmal re-bleeding. The weighted average rate of re-bleeding is 11.3% with 95% confidence interval [CI]: 10.1-12.6. Statistically significant risk factor for re-bleeding were sex (OR 1.46; 95% CI: 1.11, 1.92), high systolic blood pressure [SBP] (OR 2.52; 95% CI: 1.40, 4.53), aneurysm size (OR 3.00; 95% CI: 2.06- 4.37), clinical condition (Hunt & Hess) (OR 4.94; 95% CI: 2.29, 10.68), and Fisher Grade (OR 2.29; 95% CI: 1.45, 3.61).

Conclusion: Sex, high SBP, high Fisher Grade, aneurysm size larger than 10 mm, and patients with poor clinical condition (Hunt & Hess) were independent risk factors for aneurysmal re-bleeding. The importance of early aneurysm intervention should be emphasized to eliminate the risk of re-bleeding and poor outcome.

Endovascular internal carotid artery trapping for ruptured blood blister-like aneurysms: long-term results from a single centre

INTRODUCTION

Endovascular internal carotid artery (ICA) trapping was performed to treat ruptured blood blister-like aneurysms (BBAs). The aim of this study was to evaluate the procedural risks and long-term follow-up results.

METHODS

The records of 11 consecutive patients with BBAs who underwent endovascular ICA trapping between 2005 and 2010 were reviewed. Clinical outcomes were assessed with modified Rankin Scale (mRS) scores.

RESULTS

Endovascular ICA trapping was performed in 11 patients as either the primary treatment (7 patients) or the secondary treatment (4 patients) after the patient underwent other treatments. Three patients underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass when balloon test occlusion (BTO) revealed inadequate collateral circulation. In the primary ICA trapping group (seven patients), six patients had good outcomes (mRS 0 in five, mRS 1 in one), and one patient had a poor outcome (mRS 6: dead). In the secondary ICA trapping group (four patients), two patients had good outcomes (mRS 0), and two patients had poor outcomes (mRS 4, 5). All ten of the surviving patients were clinically stable during the follow-up period (mean 39 months). A radiological follow-up of nine patients (mean 22 months) demonstrated stable occlusion, with the exception of one reopening of the ICA because of coil migration. Perfusion studies of nine patients (mean: 23 months) demonstrated no perfusion decrease.

CONCLUSION

Endovascular ICA trapping is an effective and durable treatment for BBAs.

Intracranial extravasation of contrast medium during diagnostic CT angiography in the initial evaluation of subarachnoid hemorrhage: report of 16 cases and review of the literature

INTRODUCTION

Three-dimensional CT angiography (3D-CTA) is increasingly used in the initial evaluation of subarachnoid hemorrhage (SAH). However, there is a risk of aneurysm re-rupture in the hyperacute phase. We sought to clarify the incidence of re-rupture and characterize the subgroup in which extravasation of contrast media was seen on 3D-CTA.

METHODS

We examined the records of 356 consecutive patients presenting to our institution with non-traumatic SAH between October 2003 and December 2011. After resuscitation, patients with poor grade SAH underwent CT then 3D-CTA while sedated, mechanically ventilated and with a target systolic blood pressure of 120 mmHg.

RESULTS

336 patients underwent 3D-CTA; 20 died without return of spontaneous circulation. Extravasated contrast medium was seen in 16 (4.8%), 15 (4.5%) at the initial evaluation. Their World Federation of Neurosurgical Societies Grade was V; one patient was resuscitated from cardiac arrest. The mean times from onset to arrival and to CTA were 43.7 minutes and 71.8 minutes, respectively. Ten patients (62.5%) had episodes suggestive of aneurysm re-rupture before 3D-CTA. Surgical clipping, evacuation of hematoma and wide decompressive craniectomy was completed in six patients and one underwent coil embolization. Two of 16 patients survived: one with moderate disability and one made a good recovery.

CONCLUSIONS

Contrast extravasation was detected by 3D-CTA in 4.5% of cases despite intensive resuscitation, suggesting that continuous or intermittent rebleeding may occur frequently in the hyperacute phase. The consequences of rebleeding are devastating; however, favorable results can be obtained with immediate aneurysm repair with decompression and intensive neurocritical care.

Endovascular treatment of ruptured intracranial aneurysms

Aneurysmal subarachnoid hemorrhage (SAH) is a catastrophic neurologic event. Early triage of patients with SAH should include cardiopulmonary stabilization, neurologic assessment, and imaging. Conventional angiography with 3-dimensional rendering is necessary to accurately assess aneurysm morphology and location, so that treatment can be planned appropriately. Current evidence suggests that coil embolization can be beneficial for aneurysms amenable to endovascular treatment. The use of remodeling techniques has expanded the range of aneurysms treatable by endovascular means. Balloon remodeling can be a powerful technique for treating ruptured aneurysms with unfavorable morphology. However, stent-assisted technique is associated with significantly higher complication rates in ruptured aneurysms and requires dual antiplatelet agents, and should therefore be considered with great caution for ruptured aneurysms. Complications of ruptured aneurysm embolization include aneurysm perforation, which should be addressed with immediate occlusion of the aneurysm, and thromboembolism, which can be managed most effectively with glycoprotein IIb/IIIa inhibitors.

Effects of hyper-early (<12 hours) endovascular treatment of ruptured intracranial aneurysms on clinical outcome

Despite the encouraging results obtained with the endovascular treatment of ruptured intracranial aneurysms, few data are available on the effects of the timing of this approach on clinical outcome. The aim of our study was to evaluate the effects of the hyper-early timing of treatment and of pre-treatment and treatment-related variables on the clinical outcome of patients with ruptured intracranial aneurysms. Five hundred and ten patients (167 M, 343 F; mean age 56.45 years) with 557 ruptured intracranial aneurysms were treated at our institution from 2000 to 2011 immediately after their admission. The total population was divided into three groups: patients treated within 12 hours (hyper-early, group A), between 12-48 hours (early, group B) and after 48 hours (delayed, group C). A statistical analysis was carried out for global population and subgroups. Two hundred and thirty-four patients (46%) were included in group A, 172 (34%) in group B and 104 (20%) in group C. Pre-treatment variables (Hunt&Hess, Fisher grades, older age) and procedure-related variable (ischaemic/haemorrhagic complications) showed a significant correlation with worse clinical outcomes. The hyper-early treatment showed no correlation with good clinical outcomes. The incidence of intra-procedural complications was not significantly different between the three groups; 1.2% of pre-treatment rebleedings were observed. The hyper-early endovascular treatment of ruptured intracranial aneurysm does not seem to be statistically correlated with good clinical outcomes although it may reduce the incidence of pre-treatment spontaneous rebleedings without being associated with a higher risk of intra-procedural complications. However, since no significant differences in terms of clinical outcome and pre-treatment rebleeding rate were observed, a hyper-early treatment is not be supported by our data.

Managing subarachnoid hemorrhage in the neurocritical care unit

Patients with aneurysmal subarachnoid hemorrhage who survive the initial hemorrhage require complex interventions to occlude the aneurysm, typically followed by a prolonged intensive care unit and hospital course to manage the complications that follow. Much of the morbidity and mortality from this disease happens in delayed fashion in the neurocritical care unit. Despite progress made in the last decades, much remains to be understood about this disease and how to best manage these patients. This article provides a review of current evidence and the authors' experience, aimed at providing practical aid to those caring for patients with this disease.

Seizures and intracranial hemorrhage

Seizures and intracranial hemorrhage are possible medical diseases that any obstetrician may encounter. This article reviews the cause, treatment, and medical management in pregnancy for seizures and intracranial hemorrhage, and how the two can overlap into preeclampsia or eclampsia. This article also highlights some challenging management issues from the obstetrician's perspective.

Early endovascular treatment of subarachnoid hemorrhage

Subarachnoid hemorrhage is an important cause of morbidity and mortality. Rebleeding is one of its major complications, which occurs mainly within the first 24 h and worsens the clinical outcome in a very dramatic way. It may be prevented by aneurysm treatment: surgical clipping or endovascular coiling. We review the evidence of and recent advances in endovascular treatment and timing of the intervention. Data supporting the benefit of early (<72 h) and ultra-early (<24 h) treatment is based on observational studies. An earlier approach may be relevant for the prevention of rebleeding and improvement of clinical outcome, but several disadvantages should be considered, such as an increased rate of periprocedural complications. Hence, a well-designed randomized controlled trial deems necessary to be able to define the optimal time of treatment. The possibility of treatment concomitant with the initial angiography should also be taken into account in this trial. This fact might represent a benefit favoring coiling over clipping in the prevention of rebleeding, and thus avoiding the inevitable delay necessary for the preparation for surgery.

European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage

BACKGROUND

Intracranial aneurysm with and without subarachnoid haemorrhage (SAH) is a relevant health problem: The overall incidence is about 9 per 100,000 with a wide range, in some countries up to 20 per 100,000. Mortality rate with conservative treatment within the first months is 50-60%. About one third of patients left with an untreated aneurysm will die from recurrent bleeding within 6 months after recovering from the first bleeding. The prognosis is further influenced by vasospasm, hydrocephalus, delayed ischaemic deficit and other complications. The aim of these guidelines is to provide comprehensive recommendations on the management of SAH with and without aneurysm as well as on unruptured intracranial aneurysm.

METHODS

We performed an extensive literature search from 1960 to 2011 using Medline and Embase. Members of the writing group met in person and by teleconferences to discuss recommendations. Search results were graded according to the criteria of the European Federation of Neurological Societies. Members of the Guidelines Committee of the European Stroke Organization reviewed the guidelines.

RESULTS

These guidelines provide evidence-based information on epidemiology, risk factors and prognosis of SAH and recommendations on diagnostic and therapeutic methods of both ruptured and unruptured intracranial aneurysms. Several risk factors of aneurysm growth and rupture have been identified. We provide recommendations on diagnostic work up, monitoring and general management (blood pressure, blood glucose, temperature, thromboprophylaxis, antiepileptic treatment, use of steroids). Specific therapeutic interventions consider timing of procedures, clipping and coiling. Complications such as hydrocephalus, vasospasm and delayed ischaemic deficit were covered. We also thought to add recommendations on SAH without aneurysm and on unruptured aneurysms.

CONCLUSION

Ruptured intracranial aneurysm with a high rate of subsequent complications is a serious disease needing prompt treatment in centres having high quality of experience of treatment for these patients. These guidelines provide practical, evidence-based advice for the management of patients with intracranial aneurysm with or without rupture. Applying these measures can improve the prognosis of SAH.

Diagnostic usefulness of intraoperative ultrasonography for unexpected severe brain swelling in ultra-early surgery for ruptured intracranial aneurysms

BACKGROUND

In ultra-early aneurysm surgery, the few hours from admission to aneurysm clipping present the greatest risk for an in-hospital recurrent hemorrhage, the development of acute hydrocephalus, and severe brain edema. Thus, severe brain swelling encountered after dural opening in a craniotomy can sometimes not be explained by a preoperative computed tomography (CT) scan. Therefore, neurosurgeons need a diagnostic tool to determine the exact cause of the brain swelling to apply appropriate intraoperative management. Accordingly, the authors propose a designated optimal ultrasound window for evaluating brain swelling during a pterional craniotomy, and assess its diagnostic usefulness and clinical impact.

METHODS

Intraoperative ultrasonography was performed during pterional craniotomies to identify the causes of severe brain swelling in 23 out of 185 patients treated using a policy of ultra-early treatment after a subarachnoid hemorrhage. Paine's point was used as the sonographic window to provide axial images showing the anterior interhemispheric fissure, lentiform nucleus, insular cortex, sylvian fissure, and ventricular system.

RESULTS

The intraoperative ultrasonography revealed significant changes from the preoperative CT findings in 9 (39.1 %) of the 23 patients. These changes included the occurrence of an intracerebral hemorrhage (ICH, n = 2) related to aneurysm rebleeding with aggravated hydrocephalus and the development (n = 5) or aggravation (n = 2) of acute hydrocephalus without rebleeding. Meanwhile, for 14 (60.9 %) of the 23 patients, the ultrasonography showed no intracranial changes. For the total 23 patients with severe brain swelling, the intraoperative management included aspiration of an ICH (n = 3), a ventriculostomy (n = 16), and medical management (n = 8) with additional mannitol and/or mild hyperventilation.

CONCLUSIONS

When severe brain swelling is encountered during a pterional craniotomy for clipping a ruptured aneurysm, an intraoperative ultrasonography technique using Paine's point as a sonographic window provides useful and reliable diagnostic information on the causes of the brain swelling, enabling the neurosurgeon to select appropriate intraoperative management.

Retrospective evaluation of nicardipine versus labetalol for blood pressure control in aneurysmal subarachnoid hemorrhage

BACKGROUND

American Heart Association/American Stroke Association guidelines for management of aneurysmal subarachnoid hemorrhage (aSAH) recommend blood pressure (BP) control, utilizing labetalol or nicardipine, but do not differentiate efficacy between the two agents. The purpose of this retrospective study was to compare BP control between labetalol and nicardipine in patients following aSAH.

METHODS

Consecutive adult patients admitted to the ICU with a diagnosis of SAH treated with labetalol or nicardipine were retrospectively identified. Patients were included if they received more than one bolus dose of labetalol or a nicardipine infusion for greater than 3 h. Patients were excluded if they were <18 years of age, experiencing an ICH, acute ischemic stroke or a TIA. Patients were stratified into two groups (labetalol vs. nicardipine) and data was collected for 72 h. The outcomes compared were time within goal mean arterial pressure (MAP), average MAP/patient, MAP variability, initial response to therapy, and treatment failure. Goal MAP was defined as 70-110 mmHg.

RESULTS

There were 103 patients evaluated (labetalol n = 43; nicardipine n = 60). Demographics and baseline MAP were similar between the two groups. Nicardipine was associated with a longer time within goal MAP (78 ± 24 vs. 58 ± 36 %, p = 0.001) and lower average MAP/patient (93 ± 11 vs. 106 ± 12 mmHg, p < 0.001). There was no difference in MAP variability between the nicardipine and labetalol groups (13 ± 5 mmHg vs. 11 ± 4 mmHg; p = 0.137). Nicardipine led to a more rapid response to therapy (F = 8.1; p = 0.005) and fewer treatment failures (0 vs. 28 %, p < 0.001).

CONCLUSIONS

Our study showed nicardipine to be associated with superior BP control versus labetalol in aSAH.

Epidemiology of subarachnoid hemorrhage, patterns of management, and outcomes in China: a hospital-based multicenter prospective study

AIMS

To conduct a large-scale analysis on epidemiology, management, and outcomes of spontaneous subarachnoid hemorrhage (SAH), and to investigate the current situation of aneurysm obliteration in China.

METHODS

A multicenter prospective cohort study involving 132 hospitals throughout China from September 2007 to August 2008 was conducted. A total of 651 patients with spontaneous SAH were evaluated.

RESULTS

The most frequent type of SAH was aneurysmal SAH (77.4%), followed by uncommon causes (17.5%) and uncertain etiologies (5.1%). For aneurysmal SAH, the cumulative mortality at 28 days, 3 months, 6 months, and 12 months was 16.9%, 21.2%, 23.6%, and 24.6%, respectively. Obliteration of aneurysms, age, Hunt and Hess grade, and history of stroke affected the 12-month mortality. In multiple regression analysis, the region, type of hospital, patient's age, history of hypertension, and nonintraventricular hemorrhage impacted aneurysm obliteration.

CONCLUSION

Aneurysmal rupture is the most common cause of spontaneous SAH in China. The percentage of aneurysm obliteration is still low in China that seems to contribute to long-term mortality. With continued training of specialists, proper allocation of healthcare resources, and establishment of stroke centers, the rate of securing aneurysms is expected to rise.

Effectiveness of nicardipine for blood pressure control in patients with subarachnoid hemorrhage

OBJECTIVE

The purpose of the study is to determine the effectiveness and safety of nicardipine infusion for controlling blood pressure in patients with subarachnoid hemorrhage (SAH).

METHODS

We prospectively evaluated 52 patients with SAH and treated with nicardipine infusion for blood pressure control in a 29 months period. The mean blood pressure of pre-injection, bolus injection and continuous injection period were compared. This study evaluated the effectiveness of nicardipine for each Fisher grade, for different dose of continuous nicardipine infusion, and for the subgroups of systolic blood pressure.

RESULTS

The blood pressure measurement showed that the mean systolic blood pressure / diastolic blood pressure (SBP/DBP) in continuous injection period (120.9/63.0 mmHg) was significantly lower than pre-injection period (145.6/80.3 mmHg) and bolus injection period (134.2/71.3 mmHg), and these were statistically significant (p < 0.001). In each subgroups of Fisher grade and different dose, SBP/DBP also decreased after the use of nicardipine. These were statistically significant (p < 0.05), but there was no significant difference in effectiveness between subgroups (p > 0.05). Furthermore, controlling blood pressure was more effective when injecting higher dose of nicardipine in higher SBP group rather than injecting lower dose in lower SBP group, and it also was statistically significant (p < 0.05). During the infusion, hypotension and cardiogenic problems were transiently combined in five cases. However, patients recovered without any complications.

CONCLUSION

Nicardipine is an effective and safe agent for controlling acutely elevated blood pressure after SAH. A more systemic study with larger patients population will provide significant results and will bring solid evidence on effectiveness of nicardipine in SAH.

Blood pressure control for acute ischemic and hemorrhagic stroke

PURPOSE OF REVIEW

Acute stroke, including the subtypes of ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), typically involves significant fluctuations in blood pressure (BP). Treatment of BP after all stroke types is controversial. In each case, there are theoretical dangers to leaving BP alone as well as altering it artificially. In this article, we review the role of BP in each stroke subtype and the existing evidence for BP optimization.

RECENT FINDINGS

Except in patients receiving thrombolytic therapy, there is insufficient evidence to recommend active BP management in ischemic stroke. In ICH, the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) trial and Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT) have demonstrated that systolic BP reduction to 140  mmHg is well tolerated and associated with attenuation of hematoma expansion. The impact of BP reduction on outcomes is being evaluated in the ongoing phase III ATACH II and INTERACT 2 trials. No evidence exists to recommend definitive BP management strategies in acute SAH, although hypertension should likely be avoided before an aneurysm is secured, and hypotension should be avoided altogether.

SUMMARY

Evidence for BP management in acute stroke is limited, although large randomized trials are currently in progress for both ischemic stroke and ICH. BP management in SAH remains woefully understudied.

Intensive care unit management of aneurysmal subarachnoid hemorrhage

The emergence of dedicated neurologic-neurosurgical intensive care units, advancements in endovascular therapies, and aggressive brain resuscitation and monitoring have contributed to overall improved outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) over the past 20 to 30 years. Still, this feared neurologic emergency is associated with substantial mortality and morbidity. Emergency care for patients with aSAH focuses on stabilization, treatment of the aneurysm, controlling intracranial hypertension to optimize cerebral perfusion, and limiting secondary brain injury. This complex disorder can be associated with many neurologic complications such as acute hydrocephalus, rebleeding, global cerebral edema, seizures, vasospasm, and delayed cerebral ischemia in addition to systemic complications such as electrolyte imbalances, cardiopulmonary injury, and infections. Background routine intensive care practices such as avoidance of hyperthermia, venous thromboembolism prophylaxis, and avoidance of severe blood glucose derangements are additional important elements of care.

The relationship between rebleeding after spontaneous SAH and APOE polymorphisms in a Chinese population

Rebleeding leads to lots of patients' disability and mortality after spontaneous subarachnoid hemorrhage (SAH), but the risk factors of rebleeding have not been fully understood. More evidence showed apolipoprotein E (apoE protein, APOE gene) influenced the outcome of spontaneous SAH. In this study, we aimed to investigate the relationship of APOE polymorphisms with rebleeding after spontaneous SAH. A total of 185 patients with spontaneous SAH were involved in the current study. Genomic DNA was extracted from venous blood samples to identify the APOE genotype by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Rebleeding was defined as acute clinical deterioration that was accompanied by computed tomography (CT) evidence of rebleeding in the subarachnoid space. A total of 21 patients occurred rebleeding in 185 patients with spontaneous SAH in the hospital. Data were analyzed by χ(2)-test and logistic regression analyses. The statistical analysis indicated no significant association between APOE genotype and rebleeding in a Chinese population.

Antihypertensives are administered selectively in emergency department patients with subarachnoid hemorrhage

Elevated blood pressure is common in patients with acute subarachnoid hemorrhage (SAH). American Heart Association guidelines do not specify a blood pressure target, but limited data suggest that systolic blood pressure (SBP)≥160 mmHg is associated with increased risk of rebleeding and neurologic decline. In a population-based study, we determined the frequency of antihypertensive therapy in emergency department (ED) patients with SAH and the proportion of those patients with SBP≥160 mmHg who received this therapy. In 2005, nontraumatic SAH cases were retrospectively ascertained at 16 hospitals in our region by screening for International Classification of Diseases Ninth Revision diagnostic codes 430-436. Blood pressure was recorded at ED presentation and also before and after any treatment with antihypertensives. Hypotension was defined as SBP<100 mmHg. The Mann-Whitney U test and χ2 test were used for comparisons. Our cohort comprised 82 patients with SAH presenting to an ED; 4 patients were excluded. The median age of the included patients was 54 years, 74.4% were female, 29.5% were black, and 31 (39.7%) had SBP≥160 mmHg. Antihypertensive therapy was given to 22 of 31 patients (70.9%) with SBP≥160 mmHg and to 4 of 47 patients (8.5%) with SBP<160 mmHg. No patients became hypotensive after receiving treatment. Age, sex, Glascow Coma Scale score, and National Institutes of Health Stroke Scale score were similar between treated and untreated patients. In the absence of definitive evidence, current blood pressure management in local EDs appears reasonable. Further studies of blood pressure management in acute SAH are warranted.

Are optimal cerebral perfusion pressure and cerebrovascular autoregulation related to long-term outcome in patients with aneurysmal subarachnoid hemorrhage?

BACKGROUND AND OBJECTIVES

Continuous assessment of the cerebrovascular autoregulation (CVA) through use of the pressure reactivity index (PRx), a moving linear correlation coefficient between mean arterial blood pressure and intracranial pressure, has been effective in optimizing cerebral perfusion pressure (CPPopt) in traumatic brain injured (TBI) patients. This study investigates the feasibility of measuring CPPopt in patients with aneurysmal subarachnoid hemorrhage (aSAH) by continuously assessing the CVA.

METHODS

Twenty-nine aSAH patients were enrolled, and data from CVA status, CPPopt, and periods when CPP was below, within, or above CPPopt were computed daily. Outcome was assessed at 6 months with the Glasgow Outcome Scale. Mann-Whitney U test was used to analyze differences in the duration of impaired CVA and duration of CPP below CPPopt in patients with good and poor outcomes. Multivariable logistic regression analysis was used to identify independent predictors of outcome.

RESULTS

CVA monitoring data were available for all 29 patients with a total monitoring time of 2757 h. The duration of impaired CVA was 36.5% (interquartile range: 24.6 to 49.8) of the total monitoring time in 15 patients with good outcome and 71.6% of the total monitoring time (51.2 to 80.0) in 14 patients with poor outcome (Mann-Whitney U test 3.295, P=0.0010). PRx-based CPPopt could be identified in 26 patients (89.6%) with a total monitoring time of 2691 h. The duration of CPP below the CPPopt range was 28.0% (interquartile range: 18.0 to 47.0) of the total monitoring time in patients with good outcome and 76.0% (48.5 to 82.5) in patients with poor outcome (Mann-Whitney U test 2.779, P=0.0054). Glasgow Coma Scale score and duration of impaired CVA were independently associated with 6-month outcome (Glasgow Coma Scale score odds ratio: 1.95, 95% confidence interval: 1.01-3.75; duration of impaired CVA odds ratio: 0.88, 95% confidence interval: 0.78-0.99).

CONCLUSIONS

The assessment of CVA and CPPopt is feasible in aSAH patients and may provide important information regarding long-term outcome. A PRx above the 0.2 threshold and a CPP below the CPPopt range are associated with worse outcome.

Rebleeding of aneurysmal subarachnoid hemorrhage in computed tomography angiography: risk factor, rebleeding pattern, and outcome analysis

OBJECTIVE

For patients with subarachnoid hemorrhage (SAH), computed tomography angiography (CTA) has been the first imaging modality for aneurysm detection. We evaluate the rate, time distribution, risk factors, and clinical outcome of aneurysmal rebleeding by CTA findings.

METHODS

Consecutive patients with SAH presenting to our hospital, a tertiary care hospital, were retrospectively included. We reviewed images for all patients receiving an initial noncontrast computed tomography scan and further CTA for nontraumatic SAH surveillance with focus on rebleeding evidence.

RESULTS

A total of 12 patients with early aneurysmal rebleeding (12/110 patients [10.9%]) within 6 hours after emergency room arrival were found with dismal outcome (50% mortality) and 3 rebleeding patterns: pattern 1 of rapid active bleeding with contrast extravasation, pattern 2 of slow active bleeding with contrast leakage in the delayed venous phase, and pattern 3 of hematoma enlargement. The risk factor and poor prognostic sign include larger aneurysm diameter (≧7 mm) and contrast extravasation during CTA.

CONCLUSIONS

Rebleeding rate of aneurysmal SAH in the hyperacute stage at less than 6 hours is 10.9% with poor prognosis in this study, especially in patients with active bleeding demonstrated in CTA.

The importance of early brain injury after subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a medical emergency that accounts for 5% of all stroke cases. Individuals affected are typically in the prime of their lives (mean age 50 years). Approximately 12% of patients die before receiving medical attention, 33% within 48 h and 50% within 30 days of aSAH. Of the survivors 50% suffer from permanent disability with an estimated lifetime cost more than double that of an ischemic stroke. Traditionally, spasm that develops in large cerebral arteries 3-7 days after aneurysm rupture is considered the most important determinant of brain injury and outcome after aSAH. However, recent studies show that prevention of delayed vasospasm does not improve outcome in aSAH patients. This finding has finally brought in focus the influence of early brain injury on outcome of aSAH. A substantial amount of evidence indicates that brain injury begins at the aneurysm rupture, evolves with time and plays an important role in patients' outcome. In this manuscript we review early brain injury after aSAH. Due to the early nature, most of the information on this injury comes from animals and few only from autopsy of patients who died within days after aSAH. Consequently, we began with a review of animal models of early brain injury, next we review the mechanisms of brain injury according to the sequence of their temporal appearance and finally we discuss the failure of clinical translation of therapies successful in animal models of aSAH.

Active bleeding in acute subarachnoid hemorrhage observed by multiphase dynamic-enhanced CT

BACKGROUND AND PURPOSE

Acute SAH is reportedly associated with rebleeding from aneurysms, and recent advances in imaging technology allow us to visualize active bleeding in SAH cases. This study aimed to retrospectively investigate the incidence and characteristics of active bleeding in patients with spontaneous SAH by using multiphase dynamic-enhanced CT.

MATERIALS AND METHODS

We retrospectively surveyed a series of patients with SAH who underwent CTP with 18-phase dynamic enhancement and confirmed the presence of extravasated contrast medium in the source image. We compared clinical features between 2 groups of patients with and without extravasation.

RESULTS

Active bleeding was observed with increasing enhancement in 25.5% (13/51) of patients. All patients with extravasation were in Claassen grade 3 or 4 and WFNS grades 3, 4, or 5. The other group without extravasation included patients in all grades. A significant difference was observed in Claassen grade, WFNS grade, and increase of hematomas in follow-up CT (P < .05, for each) between the 2 groups. All CTP results of patients with extravasation were obtained within 2 hours of the onset of symptoms of SAH (P < .05). There was no significant difference in mortality at 14 days between the 2 groups (P = .128).

CONCLUSIONS

A high incidence of active bleeding (25.5%) was detected by multiphase dynamic-enhanced CT in patients with acute SAH. These results indicate that an awareness of active bleeding in patients with SAH has the potential to affect the treatment strategy.

ICU management of aneurysmal subarachnoid hemorrhage

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (SAH) has very high morbidity and mortality rates. Optimal intensive care unit (ICU) management requires knowledge of the potential complications that occur in this patient population.

METHODS

Review of the ICU management of SAH. Level of evidence for specific recommendations is provided.

RESULTS

Grading scales utilizing clinical factors and brain imaging studies can help in determining prognosis and are reviewed. Misdiagnosis of SAH is fairly common so the clinical symptoms and signs of SAH are summarized. The ICU management of SAH is discussed beginning with a focus on avoiding aneurysm re-rupture and securing the aneurysm, followed by a review of the neurologic and medical complications that may occur after the aneurysm is secured. Detailed treatment strategies and areas of current and future research are reviewed.

CONCLUSIONS

The ICU management of the patient with SAH can be particularly challenging and requires an awareness of all potential neurologic and medical complications and their urgent treatments.

Hemodynamic management of subarachnoid hemorrhage

Hemodynamic augmentation therapy is considered standard treatment to help prevent and treat vasospasm and delayed cerebral ischemia. Standard triple-H therapy combines volume expansion (hypervolemia), blood pressure augmentation (hypertension), and hemodilution. An electronic literature search was conducted of English-language papers published between 2000 and October 2010 that focused on hemodynamic augmentation therapies in patients with subarachnoid hemorrhage. Among the eligible reports identified, 11 addressed volume expansion, 10 blood pressure management, 4 inotropic therapy, and 12 hemodynamic augmentation in patients with unsecured aneurysms. While hypovolemia should be avoided, hypervolemia did not appear to confer additional benefits over normovolemic therapy, with an excess of side effects occurring in patients treated with hypervolemic targets. Overall, hypertension was associated with higher cerebral blood flow, regardless of volume status (normo- or hypervolemia), with neurological symptom reversal seen in two-thirds of treated patients. Limited data were available for evaluating inotropic agents or hemodynamic augmentation in patients with additional unsecured aneurysms. In the context of sparse data, no incremental risk of aneurysmal rupture has been reported with the induction of hemodynamic augmentation.

Impact of ultra-early coiling on clinical outcome after aneurysmal subarachnoid hemorrhage in elderly patients

RATIONALE AND OBJECTIVES

The incidence of aneurysmal subarachnoid hemorrhage is increasing in the elderly as life expectancy increases. The purpose of this study was to analyze whether ultra-early coiling of ruptured intracranial aneurysms improves clinical outcomes in elderly patients.

MATERIALS AND METHODS

Records of patients (aged ≥ 70 years) with aneurysmal subarachnoid hemorrhage treated with endovascular coiling were retrieved. Patients were classified into two groups: group A (patients coiled within 24 hours of subarachnoid hemorrhage) and group B (patients coiled ≥24 hours after subarachnoid hemorrhage). For each group, patient demographics, World Federation of Neurological Surgeons clinical grade, Fisher computed tomographic grade, aneurysm characteristics, and clinical outcomes were recorded. Outcomes were measured using the Modified Rankin Scale at 6 months.

RESULTS

Fifty-six patients were coiled within 24 hours of subarachnoid hemorrhage (group A) and 40 patients at ≥24 hours after subarachnoid hemorrhage (group B). Groups A and B had similar clinical and angiographic characteristics. Clinical outcomes showed that a total of 87.5% of patient (49 of 56) in group A were independent (Modified Rankin Scale score 0-2) compared with 70.0% of patients (28 of 40) in group B (P = .034). In multivariate logistic regression analysis, ultra-early coiling (odds ratio, 3.860; 95% confidence interval, 1.125-13.249; P = .032) proved to be an independent predictor of better clinical outcome (Modified Rankin Scale score 0-2).

CONCLUSIONS

Ultra-early (<24 hours after subarachnoid hemorrhage) coiling of ruptured aneurysms was marginally associated with improved clinical outcomes compared to coiling at ≥24 hours in elderly patients. Larger, prospective studies are required to adequately assess outcome differences between these two groups.

Antifibrinolytic therapy in the management of aneurismal subarachnoid hemorrhage revisited. A meta-analysis

BACKGROUND

To reassess the use of antifibrinolytics (AF) in the management of aneurysmal subarachnoid hemorrhage (SAH) in the setting of present-day treatment strategies.

METHOD

The authors conducted a systematic review of the literature and a meta-analysis. They reviewed the PubMed database and conducted a manual review of article bibliographies.

RESULTS

Using a pre-specified search strategy, 17 relevant studies involving a total of 2,872 patients with SAH at baseline, from which data of 1,380 patients having received AF, were included in a meta-analysis. Pooled odds ratios of the impact of AF on functional outcomes, rebleeding, and cerebral infarction were calculated. Short-term use of AF (72 h or less) associated with medical prevention of ischemic deficit seems to yield better results on functional outcome than long-term use of AF, especially if not associated with a medical prevention of ischemic deficit. The risk of cerebral infarction is not increased by the short-term use of AF and the risk of rebleeding is decreased independently of the length of AF use.

CONCLUSIONS

The use of AF should be reconsidered in the setting of modern-era treatment strategies, as the short-term use associated with medical prevention of ischemic deficit decreases the rate of rebleeding and does not increase the risk of cerebral infarction, thus potentially yielding better protection against poor functional outcome.

Role of calcitonin gene-related peptide in cerebral vasospasm, and as a therapeutic approach to subarachnoid hemorrhage

Calcitonin gene-related peptide (CGRP) is one of the most potent microvascular vasodilators identified to date. Vascular relaxation and vasodilation is mediated via activation of the CGRP receptor. This atypical receptor is made up of a G protein-coupled receptor called calcitonin receptor-like receptor (CLR), a single transmembrane protein called receptor activity-modifying protein (RAMP), and an additional protein that is required for Ga(s) coupling, known as receptor component protein (RCP). Several mechanisms involved in CGRP-mediated relaxation have been identified. These include nitric oxide (NO)-dependent endothelium-dependent mechanisms or cAMP-mediated endothelium-independent pathways; the latter being more common. Subarachnoid hemorrhage (SAH) is associated with cerebral vasoconstriction that occurs several days after the hemorrhage and is often fatal. The vasospasm occurs in 30-40% of patients and is the major cause of death from this condition. The vasoconstriction is associated with a decrease in CGRP levels in nerves and an increase in CGRP levels in draining blood, suggesting that CGRP is released from nerves to oppose the vasoconstriction. This evidence has led to the concept that exogenous CGRP may be beneficial in a condition that has proven hard to treat. The present article reviews: (a) the pathophysiology of delayed ischemic neurologic deficit after SAH (b) the basics of the CGRP receptor structure, signal transduction, and vasodilatation mechanisms and (c) the studies that have been conducted so far using CGRP in both animals and humans with SAH.