2001
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Effects of remifentanil on in-hospital mortality and length of stay following clipping of intracranial aneurysm: a propensity score-matched analysis. J Neurosurg Anesthesiol 2015; 26:291-8. [PMID: 24504170 DOI: 10.1097/ana.0000000000000039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Remifentanil is an ultrashort-acting µ-opioid receptor agonist and is especially suitable for neuroanesthesia. We previously reported that general anesthesia with remifentanil for brain tumor resection was associated with lower postoperative mortality and shorter postoperative length of stay (LOS) when compared with surgeries without remifentanil. This phenomenon may also exist during clipping of intracranial aneurysms (ICAs), where brain tissue frequently suffers ischemia and reperfusion injury. We performed a propensity score-matching study to compare in-hospital mortality and postoperative LOS with and without remifentanil in such patients. METHODS We used the Diagnosis Procedure Combination inpatient database in Japan that includes 926 acute care hospitals to identify patients who underwent clipping of ICAs under general anesthesia between July and December 2007. RESULTS Of the 4502 patients who underwent ICA clipping, 1380 propensity-matched pairs (n=2760) were included for outcome comparison. The remifentanil group had significantly lower in-hospital mortality than the nonremifentanil group (4.2% vs. 7.7%; P<0.001). Use of remifentanil was an independent factor for lower in-hospital mortality (odds ratio=0.52; 95% confidence interval, 0.37-0.74; P<0.001). By contrast, postoperative LOS did not differ significantly between the 2 groups. There was no difference in the occurrence of postoperative complications except for hydrocephalus, which was more common with remifentanil. CONCLUSIONS This retrospective observational study demonstrated a possible relationship between the use of remifentanil for neuroanesthesia and reduced mortality of patients undergoing clipping of ICAs with open craniotomy. Prospective interventional studies are necessary to confirm this relationship.
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2002
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Höllig A, Thiel M, Stoffel-Wagner B, Coburn M, Clusmann H. Neuroprotective properties of dehydroepiandrosterone-sulfate and its relationship to interleukin 6 after aneurysmal subarachnoid hemorrhage: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:231. [PMID: 25993987 PMCID: PMC4462180 DOI: 10.1186/s13054-015-0954-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/15/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The established neuroprotective property of the sex steroid precursor dehydroepiandrosterone-sulfate (DHEAS) has not yet been investigated in the context of aneurysmal subarachnoid hemorrhage (aSAH). The influence of DHEAS on inflammatory response resulting in modulation of interleukin 6 (IL-6) synthesis has been shown. Here, we evaluate DHEAS serum levels after aSAH (day 0-14) and levels of IL-6 related to functional outcome at discharge and at six months. METHODS A complete data set (DHEAS and IL-6 serum levels for days 0, 1, 4, 7, 10 and 14 after aSAH) and outcome assessment at discharge according to modified Rankin Scale score (mRS) was available for 53 patients of the initially screened cohort (n = 109). Outcome assessment six months after aSAH was obtained from 41 patients. Logarithmized levels of DHEAS and IL-6 were related to dichotomized functional outcome either assessed at discharge or at six months. A mixed between-within subjects ANOVA was applied for statistical analysis (SPSS 21.0). RESULTS DHEAS and IL-6 levels across time were related to functional outcome. Regarding outcome assessment at discharge and at six months after aSAH, DHEAS levels (transformed to square root for statistical purposes) were considerably higher in patients with favorable outcome (mRS 0-2) (p = .001; p = .020). Inversely, in patients with favorable outcome either at discharge or six months after aSAH, lower IL-6 levels (logarithmized for statistical purposes) were observed across time (both p < .001). CONCLUSION We provide new evidence that DHEAS is associated with protective properties resulting in improvement of functional outcome after aSAH, possibly by influencing the inflammatory response after aSAH shown in the decreasing IL-6 serum levels. But the results for outcome six months after SAH are limited due to a high drop-out rate.
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Affiliation(s)
- Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Pauwelsstr. 30, D-52074, Aachen, Germany. .,Department of Anesthesiology, RWTH Aachen University, Aachen, Germany.
| | - Miriam Thiel
- Department of Pediatrics, GFO Kliniken Bonn Zweigstelle St. Marien-Hospital, Bonn, Germany.
| | - Birgit Stoffel-Wagner
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn, Bonn, Germany.
| | - Mark Coburn
- Department of Anesthesiology, RWTH Aachen University, Aachen, Germany.
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Pauwelsstr. 30, D-52074, Aachen, Germany.
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2003
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Mine B, Tancredi I, Aljishi A, Alghamdi F, Beltran M, Herchuelz M, Lubicz B. Follow-up of intracranial aneurysms treated by a WEB flow disrupter: a comparative study of DSA and contrast-enhanced MR angiography. J Neurointerv Surg 2015; 8:615-20. [DOI: 10.1136/neurintsurg-2015-011644] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 05/04/2015] [Indexed: 11/03/2022]
Abstract
ObjectiveTo compare contrast-enhanced MR angiography (CE-MRA) and DSA for the follow-up of intracranial aneurysms (IAs) treated with the Woven EndoBridge embolization system DL (WEB DL; Sequent Medical, Aliso Viejo, California, USA).Materials and methodsWe retrospectively identified all patients treated with a WEB DL between November 2010 and February 2013 in 2 hospitals. The IA occlusion was graded on follow-up CE-MRA and DSA by 4 independent readers and by 2 readers reaching a consensus, respectively. Interobserver agreement for MRA and intertechnique agreement was evaluated by calculating linear weighted κ.ResultsFifteen patients with 16 IAs were included. Mean delay between MRA and DSA was 2 months (range 0–16 months). Interobserver agreement for MRA was substantial to almost perfect (κ=0.686–0.921; mean κ=0.809). Intertechnique agreement was moderate to substantial (κ=0.579–0.724; mean κ=0.669). Only three out of five inadequately occluded IAs were detected by MRA.ConclusionsCE-MRA is a useful tool for the follow-up of IAs treated with a WEB DL. However, early follow-up with DSA remains mandatory to detect inadequately occluded IAs.
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2004
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Bösel J, Möhlenbruch M, Sakowitz OW. [News and perspectives in neurocritical care]. DER NERVENARZT 2015; 85:928-38. [PMID: 25096787 DOI: 10.1007/s00115-014-4040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neurocritical care is an ever-evolving discipline and its implementation in intensive care leads to reduction in mortality and to improvement of functional outcome in patients with devastating injuries to the nervous system. However, the decisive elements of the complete field of neurocritical care remain relatively unclear, as well as the exact ways to optimize them. During recent years new insights have been gained and new exciting studies have been initiated from which results are soon to be expected. This review focuses on the following management aspects: neuromonitoring, airway and ventilation, endovascular therapy, cerebrospinal fluid drainage, decompressive craniectomy, hematoma evacuation, blood pressure, and targeted temperature management. The application of these measures to brain diseases and injuries frequently treated in neurointensive care units will be addressed in the context of current studies.
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Affiliation(s)
- J Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland,
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2005
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Caspers J, Rubbert C, Turowski B, Martens D, Reichelt DC, May R, Aissa J, Hänggi D, Etminan N, Mathys C. Timing of Mean Transit Time Maximization is Associated with Neurological Outcome After Subarachnoid Hemorrhage. Clin Neuroradiol 2015; 27:15-22. [PMID: 25939528 DOI: 10.1007/s00062-015-0399-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/15/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE Computed tomography perfusion (CTP) has gained significant relevance for the radiological screening of patients at risk of developing delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Particularly, the impact of MTTPEAK, i.e., the maximal mean transit time value in a series of CTP measurements, for the prediction of long-term outcome has recently been demonstrated by our group. Complementing this recent work, the present study investigated how the timing of MTTPEAK affected the long-term outcome after aneurysmal subarachnoid hemorrhage. METHODS CTP examinations from 103 patients with clinical deterioration attributed to DCI after aSAH were retrospectively analyzed for time interval between SAH ictus and onset of MTTPEAK in association with modified Rankin Scale (mRS) 23.1 months after SAH. RESULTS Patients with unfavorable outcome (mRS > = 2) suffered significant earlier MTTPEAK onsets than patients with favorable outcome (mRS = 0 and 1). MTTPEAK within the first week was associated with significantly higher mRS scores compared to later MTTPEAK. Timing of MTTPEAK together with the value of MTTPEAK and initial World Federation of Neurosurgical Societies (WFNS) grade was a significant predictor for an unfavorable outcome (mRS > = 2). CONCLUSIONS The current findings suggest a presumably higher vulnerability of the brain to early microcirculatory impairments after aSAH and highlight that timing of MTT elevations could be considered for the identification of patients at increased risk for poor neurological outcome due to DCI.
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Affiliation(s)
- J Caspers
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, 52425, Jülich, Germany
| | - C Rubbert
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany.
| | - B Turowski
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D Martens
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D C Reichelt
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - R May
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - J Aissa
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University, 40225, Dusseldorf, Germany
| | - N Etminan
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University, 40225, Dusseldorf, Germany
| | - C Mathys
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
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2006
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Sullivan R, Duncan K, Dailey T, Kaneko Y, Tajiri N, Borlongan CV. A possible new focus for stroke treatment - migrating stem cells. Expert Opin Biol Ther 2015; 15:949-58. [PMID: 25943632 DOI: 10.1517/14712598.2015.1043264] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Stroke is a leading cause of mortality in the US. More so, its infliction often leaves patients with lasting morbidity and deficits. Ischemic stroke comprises nearly 90% of incidents and the majority of medical treatment aims at reestablishing perfusion and preventing recurrence. AREAS COVERED Long-term options for neurorestoration are limited by the infancy of their innovative approach. Accumulating evidence suggests the therapeutic potential of stem cells in neurorestoration, however, proper stem cell migration remains a challenge in translating stem cell therapy from the laboratory to the clinic. In this paper, we propose the role that exogenous stem cell transplantation may serve in facilitating the migration of endogenous stem cells to the site of injury, an idea termed 'biobridge'. EXPERT OPINION Recent research in the field of traumatic brain injury has provided a foundational understanding that, through the use of exogenous stem cells, native tissue architecture may be manipulated by proteinases to allow better communication between the endogenous sites of neural stem cells and the regions of injury. There is still much to be learned about these mechanisms, though it is the devastating nature of stroke that necessitates continued research into the prospective therapeutic potential of this novel approach.
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Affiliation(s)
- Robert Sullivan
- University of South Florida College of Medicine, Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair , 12901 Bruce B. Downs Blvd, Tampa, FL , USA +1 813 974 3154 ; +1 813 974 3078 ;
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2007
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Serum levels of nimodipine in enteral and parenteral administration in patients with aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2015; 157:763-7. [PMID: 25701099 DOI: 10.1007/s00701-015-2369-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/02/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to evaluate serum nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage (SAH) after parenteral therapy and a following course of enteral administration. METHODS SAH patients were treated with intravenous nimodipine (2 mg/h) during the 1st week after hemorrhage, and on day 8, we switched over to enteral administration (60 mg/4 h), either orally or by gavage. Serum nimodipine concentrations were measured on days 3, 5, 8, 9 and 12. Area under the curve (AUC) was calculated during parenteral and enteral therapy. The data of 15 patients were analyzed retrospectively. RESULTS In this study, 157 blood samples were obtained. In seven samples, during the administration by gavage to two patients with high-grade SAH, the serum nimodipine concentrations were negligible. The AUC values during parenteral administration (median 149.3 ng-h/ml) were significantly higher than during oral administration on days 9 (median 92.1 ng-h/ml) and 12 (median 44.1 ng-h/ml) in seven patients (p = 0.030 and p = 0.016, respectively). The AUC values during parenteral administration were significantly higher than during administration by gavage on day 9 in eight patients (median 87.9 and 34 ng-h/ml, respectively, p = 0.001). The AUC values during enteral administration were higher in patients who received nimodine orally than in those who received it by gavage (median 52.3 and 23.1 ng-h/ml, respectively, p = 0.006). CONCLUSIONS Enteral administration of nimodipine showed lower bioavailability during the 2nd week after SAH compared to parenteral application during the 1st week. Negligible serum concentrations were even expected when nimodipine was given by gavage in patients with high-grade SAH, thus suggesting that parenteral administration may be the better route in these patients.
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2008
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Tkachev VV, Shagal LV, Muzlaev GG. [The use of transcallosal ventriculostomy to treat complicated forms of aneurismal intracranial hemorrhages]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:48-57. [PMID: 25909745 DOI: 10.17116/neiro201579148-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The present paper reports two cases of successful use of the anterior interhemispheric transcallosal approach during ultra-early surgery in patients in decompensated condition with severe intraventricular hemorrhage caused by rupture of cerebral aneurysms.
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Affiliation(s)
- V V Tkachev
- Regional Clinical Hospital #1, Krasnodar Region, Russia
| | - L V Shagal
- Regional Clinical Hospital #1, Krasnodar Region, Russia
| | - G G Muzlaev
- Regional Clinical Hospital #1, Krasnodar Region, Russia
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2009
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Blood Pressure Guideline Adherence in Patients with Ischemic and Hemorrhagic Stroke in the Neurointensive Care Unit Setting. Neurocrit Care 2015; 23:313-20. [DOI: 10.1007/s12028-015-0116-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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2010
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2011
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Kofler M, Schiefecker A, Ferger B, Beer R, Sohm F, Broessner G, Hackl W, Rhomberg P, Lackner P, Pfausler B, Thomé C, Schmutzhard E, Helbok R. Cerebral Taurine Levels are Associated with Brain Edema and Delayed Cerebral Infarction in Patients with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2015; 23:321-9. [DOI: 10.1007/s12028-015-0140-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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2012
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Zhao B, Zhao Y, Tan X, Cao Y, Wu J, Zhong M, Wang S. Factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage: a multicentre retrospective analysis. BMJ Open 2015; 5:e007410. [PMID: 25877280 PMCID: PMC4401840 DOI: 10.1136/bmjopen-2014-007410] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To determine factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage (aSAH). DESIGN A multicentre retrospective analysis, observational study. SETTING High-volume teaching hospitals (more than 150 aSAH cases per year). PARTICIPANTS 118 patients with World Federation of Neurosurgical Societies (WFNS) grades IV and V underwent surgical treatment. Ultra-early surgery was defined as surgery performed within 24 h of aSAH, and delayed surgery as surgery performed after 24 h. Outcome was assessed by modified Rankin Scale (mRS). The mean time of follow-up was 12.5±3.4 months (range 6-28 months). RESULTS 47 (40%) patients underwent ultra-early surgery, and 71 (60%) patients underwent delayed surgery. Patients with WFNS grade V (p=0.011) and brain herniation (p=0.004) more often underwent ultra-early surgery. Postoperative complications were similar in ultra-early and delayed surgery groups. Adjusted multivariate analysis showed the outcomes were similar between the two groups. Multivariate analysis of predictors of poor outcome, ultraearly surgery was not an independent predictor of poor outcome, while advanced age, postresuscitation WFNS V grade, intraventricular haemorrhage, brain herniation and non-middle cerebral artery (MCA) aneurysms were associated with poor outcome. CONCLUSIONS Although patients with WFNS grade V and brain herniation more often undergo ultra-early surgery, postoperative complications and outcomes in selected patients were similar in the two groups. Patients of younger age, WFNS grade IV, absence of intraventricular haemorrhage, absence of brain herniation and MCA aneurysms are more likely to have a good outcome. Ultra-early surgery could improve outcomes in carefully selected patients with poor-grade aSAH.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Xianxi Tan
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Ming Zhong
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
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2013
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Seicean A, Alan N, Seicean S, Neuhauser D, Selman WR, Bambakidis NC. Risks associated with preoperative anemia and perioperative blood transfusion in open surgery for intracranial aneurysms. J Neurosurg 2015; 123:91-100. [PMID: 25859810 DOI: 10.3171/2014.10.jns14551] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Preoperative anemia may be treated with a blood transfusion. Both are associated with adverse outcomes in various surgical procedures, but this has not been clearly elucidated in surgery for cerebral aneurysms. In this study the authors assessed the association of preoperative anemia and perioperative blood transfusion, separately, on 30-day morbidity and mortality in patients undergoing open surgery for ruptured and unruptured intracranial aneurysms. METHODS The authors identified 668 cases (including 400 unruptured and 268 unruptured intracranial aneurysms) of open surgery for treatment of intracranial aneurysms in the 2006-2012 National Surgical Quality Improvement Program, a validated and reproducible prospective clinical database. Anemia was defined as a hematocrit level less than 39% in males and less than 36% in females. Perioperative transfusion was defined as at least 1 unit of packed or whole red blood cells given at any point between the start of surgery to 72 hours postoperatively. The authors separately compared surgical outcome between patients with (n = 198) versus without (n = 470) anemia, and those who underwent (n = 78) versus those who did not receive (n = 521) a transfusion, using a 1:1 match on propensity score. RESULTS In the matched cohorts, all observed covariates were comparable between anemic (n = 147) versus nonanemic (n = 147) and between transfused (n = 67) versus nontransfused patients (n = 67). Anemia was independently associated with prolonged hospital length of stay (LOS; odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.5), perioperative complications (OR 1.9, 95% CI 1.1-3.1), and return to the operating room (OR 2.1, 95% CI 1.1-4.5). Transfusion was also independently associated with perioperative complications (OR 2.4, 95% CI 1.1-5.3). CONCLUSIONS Preoperative anemia and transfusion are each independent risk factors for perioperative complications in patients undergoing surgery for cerebral aneurysms. Perioperative anemia is also associated with prolonged hospital LOS and 30-day return to the operating room.
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Affiliation(s)
- Andreea Seicean
- Case Western Reserve University School of Medicine;,Department of Epidemiology and Biostatistics, Case Western Reserve University;
| | - Nima Alan
- Case Western Reserve University School of Medicine
| | - Sinziana Seicean
- Departments of 3 Pulmonary, Critical Care, and Sleep Medicine, University Hospitals;,Heart and Vascular Institute, Cleveland Clinic; and
| | | | - Warren R Selman
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Nicholas C Bambakidis
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
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2014
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English SW, Chassé M, Turgeon AF, Tinmouth A, Boutin A, Pagliarello G, Fergusson D, McIntyre L. Red blood cell transfusion and mortality effect in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis protocol. Syst Rev 2015; 4:41. [PMID: 25927348 PMCID: PMC4392797 DOI: 10.1186/s13643-015-0035-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease that leads to important morbidity and mortality in a young patient population. Anemia following aSAH is common and may be exacerbated by the treatments instituted by clinicians as part of standard care. The role and optimal thresholds for red blood cell (RBC) transfusion in this patient population remains unknown. METHODS/DESIGN We will conduct a systematic review of the literature using MEDLINE, EMBASE, and EBM Reviews (including Cochrane Central databases) using a comprehensive search strategy for observational and interventional studies of RBC transfusion in aSAH. Our primary objective is to evaluate the association of RBC transfusion with mortality in aSAH patients. Secondary objectives include a) determining associations between RBC transfusion and poor neurologic outcome, b) defining an optimal RBC transfusion threshold in aSAH patients, and c) describing complications associated with RBC transfusion in aSAH patients. We plan a descriptive reporting of all included citations including study characteristics, methodological quality, and reported outcomes. Clinical and statistical heterogeneity observed between studies will be described. If appropriate, meta-analyses of suitable studies and interpretation of their results will be performed. Effect measures will be converted to obtain relative risks and odds ratios (RR and ORs) with 95% confidence intervals and pooled according to study design (randomized trials and observational studies respectively) using a random effects model. DISCUSSION This review will summarize the existing observational and trial evidence regarding RBC transfusion in aSAH patients. The analytical plan has made considerations for different study designs, both observational and interventional in nature, and will summarize the best available evidence to inform the end user and policy and guideline producers and to highlight areas in need of further study. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014014806.
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Affiliation(s)
- Shane W English
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Rm F202, Ottawa, ON, K1Y 4E9, Canada. .,Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| | - Michaël Chassé
- Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| | - Alexis F Turgeon
- Department of Anesthesia (Critical Care), Hôpital L'Enfant-Jésus, 1401, 18e Rue, H-037, Québec, QB, G1J 1Z4, Canada.
| | - Alan Tinmouth
- Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| | - Amélie Boutin
- Department of Anesthesia (Critical Care), Hôpital L'Enfant-Jésus, 1401, 18e Rue, H-037, Québec, QB, G1J 1Z4, Canada.
| | - Giuseppe Pagliarello
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Rm F202, Ottawa, ON, K1Y 4E9, Canada.
| | - Dean Fergusson
- Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Rm F202, Ottawa, ON, K1Y 4E9, Canada. .,Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada.
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2015
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Diffuse Patterns of Nonaneurysmal Subarachnoid Hemorrhage Originating from the Basal Cisterns Have Predictable Vasospasm Rates Similar to Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:795-801. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/22/2014] [Accepted: 11/14/2014] [Indexed: 11/20/2022] Open
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2016
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Boogaarts HD, van Lieshout JH, van Amerongen MJ, de Vries J, Verbeek ALM, Grotenhuis JA, Westert GP, Bartels RHMA. Aneurysm diameter as a risk factor for pretreatment rebleeding: a meta-analysis. J Neurosurg 2015; 122:921-8. [DOI: 10.3171/2014.12.jns14931] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Aneurysmal rerupture prior to treatment is a major cause of death and morbidity in aneurysmal subarachnoid hemorrhage. Recognizing risk factors for aneurysmal rebleeding is particularly relevant and might help to identify the aneurysms that benefit from acute treatment. It is uncertain if the size of the aneurysm is related to rebleeding. This meta-analysis was performed to evaluate whether an association could be determined between aneurysm diameter and the rebleeding rate before treatment. Potentially confounding factors such age, aneurysm location, and the presence of hypertension were also evaluated.
METHODS
The authors systematically searched the PubMed, Embase, and Cochrane databases up to April 3, 2013, for studies of patients with aneurysmal subarachnoid hemorrhage that reported the association between aneurysm diameter and pretreatment aneurysmal rebleeding. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were used to evaluate study quality.
RESULTS
Seven studies, representing 2121 patients, were included in the quantitative analysis. The quality of the studies was low in 2 and very low in 5. Almost all of the studies used 10 mm as the cutoff point for size among other classes, and only one used 7 mm. An analysis was performed with this best unifiable cutoff point. Overall rebleeding occurred in 360 (17.0%) of 2121 patients (incidence range, from study to study, 8.7%–28.4%). The rate of rebleeding in small and large aneurysms was 14.0% and 23.6%, respectively. The meta-analysis of the 7 studies revealed that larger size aneurysms were at a higher risk for rebleeding (OR 2.56 [95% CI 1.62–4.06]; p = 0.00; I2 = 60%). The sensitivity analysis did not alter the results. Five of the 7 studies reported data regarding age; 4 studies provided age-adjusted results and identified a persistent relationship between lesion size and the risk of rebleeding. The presence of hypertension was reported in two studies and was more prevalent in patients with rebleeding in one of these. Location (anterior vs posterior circulation) was reported in 5 studies, while in 4 there was no difference in the rebleeding rate. One study identified a lower risk of rebleeding associated with posterior location aneurysms.
CONCLUSIONS
This meta-analysis showed that aneurysm size is an important risk factor for aneurysmal rebleeding and should be used in the clinical risk assessment of individual patients. The authors' results confirmed the current guidelines and underscored the importance of acute treatment for large ruptured aneurysms.
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Affiliation(s)
| | | | | | | | | | | | - Gert P. Westert
- 4Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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2017
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2018
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A clinical characteristic analysis of pregnancy-associated intracranial haemorrhage in China. Sci Rep 2015; 5:9509. [PMID: 25819941 PMCID: PMC4377582 DOI: 10.1038/srep09509] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 03/05/2015] [Indexed: 11/29/2022] Open
Abstract
Intracerebral haemorrhage (ICH) occurring during pregnancy and the puerperium is an infrequent but severe complication with a high mortality and poor prognosis. Until recently, previous studies have mainly focused on the effect of different treatments on prognosis. However, few studies have provided solid evidence to clarify the key predisposing factors affecting the prognosis of ICH. In the present study, based on a unique sample with a high ICH incidence and mortality rate, we described the main clinical characteristics of ICH patients and found that the prognosis of patients who underwent surgical intervention was not better than that of patients who received other treatment modalities. However, pre-eclampsia patients had higher maternal and neonatal mortality rates than other aetiology groups. Furthermore, univariate regression analysis identified onset to diagnosis time (O-D time) and pre-eclampsia as the only factors showing independent correlation with poor maternal outcomes (modified Rankin Scale, mRS ≥ 3), and only O-D time was identified as a predictor of maternal mortality. These results revealed that the aetiology of ICH and O-D time might be crucial predisposing factors to prognosis, especially for patients with pre-eclampsia. The study highlighted a novel direction to effectively improve the prognosis of pregnancy-associated ICH.
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2019
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Rabinstein AA. Critical care of aneurysmal subarachnoid hemorrhage: state of the art. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:239-42. [PMID: 25366630 DOI: 10.1007/978-3-319-04981-6_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Subarachnoid hemorrhage (SAH) from a ruptured aneurysm is a very complex disease. The brain can be injured from the immediate effects of the acute bleeding, but can also be threatened by secondary insults hours and days later. Early and delayed systemic complications are common and can be very serious. This brief paper summarizes key practical concepts regarding the neurocritical care of patients with aneurysmal SAH (aSAH). It proposes as a framework the division of the time course of the disease into a first phase (from aneurysm rupture to aneurysm treatment) of resuscitation and stabilization and a second phase (from aneurysm treatment to the end of the acute hospitalization) of prevention and treatment of secondary insults. The main mechanisms of cerebral injury and the principal systemic complications are discussed and diagnostic and therapeutic advice is provided based on a combination of available evidence and clinical experience.
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Affiliation(s)
- Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic, 200 First Street SW, Mayo W8B, Rochester, MN, 55905, USA,
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2020
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Yoganand A, Wood RP, Jimenez C, Siddiqui A, Snyder K, Nagesh SVS, Bednarek DR, Rudin S, Baier R, Ionita CN. Angiographic analysis for phantom simulations of endovascular aneurysm treatments with a new fully retrievable asymmetric flow diverter. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2015; 9417. [PMID: 26869741 DOI: 10.1117/12.2082079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Digital Subtraction Angiography (DSA) is the main diagnostic tool for intracranial aneurysms (IA) flow-diverter (FD) assisted treatment. Based on qualitative contrast flow evaluation, interventionists decide on subsequent steps. We developed a novel fully Retrievable Asymmetric Flow-Diverter (RAFD) which allows controlled deployment, repositioning and detachment achieve optimal flow diversion. The device has a small low porosity or solid region which is placed such that it would achieve maximum aneurysmal in-jet flow deflection with minimum impairment to adjacent vessels. We tested the new RAFD using a flow-loop with an idealized and a patient specific IA phantom in carotid-relevant physiological conditions. We positioned the deflection region at three locations: distally, center and proximally to the aneurysm orifice and analyzed aneurysm dome flow using DSA derived maps for mean transit time (MTT) and bolus arrival times (BAT). Comparison between treated and untreated (control) maps quantified the RAFD positioning effect. Average MTT, related to contrast presence in the aneurysm dome increased, indicating flow decoupling between the aneurysm and parent artery. Maximum effect was observed in the center and proximal position (~75%) of aneurysm models depending on their geometry. BAT maps, correlated well with inflow jet direction and magnitude. Reduction and jet dispersion as high as about 50% was observed for various treatments. We demonstrated the use of DSA data to guide the placement of the RAFD and showed that optimum flow diversion within the aneurysm dome is feasible. This could lead to more effective and a safer IA treatment using FDs.
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Affiliation(s)
- Aradhana Yoganand
- Department of Biomedical Engineering, State University of New York at Buffalo; Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo
| | - Rachel P Wood
- Department of Biomedical Engineering, State University of New York at Buffalo; Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo
| | - Carlos Jimenez
- Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo; University of Antioquia-GIB-Eafit, Medellin, Colombia
| | - Adnan Siddiqui
- Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo
| | - Kenneth Snyder
- Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo
| | - S V Setlur Nagesh
- Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo
| | - D R Bednarek
- Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo
| | - S Rudin
- Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo
| | - Robert Baier
- Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo
| | - Ciprian N Ionita
- Department of Biomedical Engineering, State University of New York at Buffalo; Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo
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2021
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Impact of specialist neurovascular care in subarachnoid haemorrhage. Clin Neurol Neurosurg 2015; 133:55-60. [PMID: 25839916 DOI: 10.1016/j.clineuro.2015.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 02/18/2015] [Accepted: 03/07/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND The management of neurosurgical disorders has become increasingly specialised. The care of patients with subarachnoid haemorrhage (SAH) has generally been part of core neurosurgical practice, provided by general neurosurgeons whatever their specialist interest. The aim of this present study therefore is to ascertain if, and to what extent care provided by a dedicated neurovascular team (compared to care provided by a general neurosurgical team) change patient disposition in SAH. METHODS This is a retrospective analysis of SAH patients, identified from a departmental database of a single neurosurgical centre. In 2008, the service was reorganised such that a neurovascular team cared for all SAH patients. We compared clinical outcome in people admitted prior to this service reorganisation (Period A, 2004-2007) with patients admitted afterwards (Period B, 2009-2011). Survival and recovery were assessed according to the Glasgow Outcome Scale (GOS). Multi-factorial logistic regression analysis was performed to determine the injury and age adjusted incidence of complications, odds of survival at discharge, discharge home, mortality, good recovery (GOS 5) and favourable outcome, by dichotomising GOS (GOS 4-5 vs. GOS 1-3) at 3 months. RESULTS 1114 patients were included in the study. The mean age of patients presenting in Period A (n = 543) was younger [50 years (SD 13.5)] than those in Period B (n = 571) [53 years (SD 13)]. Patients admitted in Period B were more likely to present as poor grade (World Federation of Neurological surgeons (WFNS) grades 4 and 5) compared to Period A (26.5% vs. 21.3%). No statistical differences between the groups in the incidence of pre-operative re-bleeding (3% vs. 5%) or rates of delayed cerebral ischaemia (16.1% vs. 16.1%) were observed. After adjustment for age, sex and injury severity, the odds of patient time to discharge, discharge home and good recovery (GOS 5) were 27% (p < 0.001), 45% (p = 0.001) and 93% (p < 0.001) higher respectively in Period B than Period A. CONCLUSIONS The data presented here demonstrates that management of SAH by a dedicated neurovascular team improves the potential for patient recovery.
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2022
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May CC, Arora S, Parli SE, Fraser JF, Bastin MT, Cook AM. Augmented Renal Clearance in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2015; 23:374-9. [DOI: 10.1007/s12028-015-0127-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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2023
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Expression of Cytoplasmic Gelsolin in Rat Brain After Experimental Subarachnoid Hemorrhage. Cell Mol Neurobiol 2015; 35:723-31. [DOI: 10.1007/s10571-015-0168-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/24/2015] [Indexed: 10/23/2022]
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2024
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Stapleton CJ, Walcott BP, Butler WE, Ogilvy CS. Neurological outcomes following intraprocedural rerupture during coil embolization of ruptured intracranial aneurysms. J Neurosurg 2015; 122:128-35. [PMID: 25361491 DOI: 10.3171/2014.9.jns14616] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraprocedural rerupture (IPR) of intracranial aneurysms during coil embolization is associated with significant periprocedural disability and death. However, whether this morbidity and mortality are secondary to an increased risk of vasospasm and hydrocephalus is unknown. The authors undertook this study to determine the in-hospital and long-term neurological outcomes for patients with aneurysmal subarachnoid hemorrhage (SAH) treated with coil embolization who suffer aneurysm rerupture during treatment. METHODS The records of 156 patients admitted with SAH from previously untreated, ruptured, intracranial aneurysms and treated with endovascular coiling between January 2007 and January 2014 were retrospectively reviewed. Twelve patients (7.7%) experienced IPR during coil embolization. RESULTS Compared with the cohort of patients with uncomplicated coil embolization procedures, patients with aneurysm rerupture were more likely to require external ventricular drain (EVD) placement (91.7% vs 58.3%, p = 0.02) and postprocedural EVD placement (36.4% vs 7.1%, p = 0.01), to undergo permanent ventriculoperitoneal shunt placement (50.0% vs 18.8%, p = 0.02), to develop symptomatic vasospasm (50.0% vs 18.1%, p = 0.02), and to have longer lengths of hospital stay (median 21.5 days vs 15.0 days, p = 0.04). Admission Hunt and Hess, modified Fisher, and Barrow Neurological Institute grades did not differ between the 2 cohorts, nor did long-term functional neurological outcomes as assessed by the modified Rankin Scale. CONCLUSIONS Intraprocedural rerupture during coil embolization for ruptured intracranial aneurysms is associated with an increased risk of symptomatic vasospasm and need for temporary and permanent cerebrospinal fluid diversion for hydrocephalus.
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2025
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Pahl FH, Oliveira MFD, Rotta JM. Natural course of subarachnoid hemorrhage is worse in elderly patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 72:862-6. [PMID: 25410453 DOI: 10.1590/0004-282x20140146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 08/08/2014] [Indexed: 11/21/2022]
Abstract
UNLABELLED Aging is a major risk factor for poor outcome in patients with ruptured or unruptured intracranial aneurysms (IA) submitted to treatment. It impairs several physiologic patterns related to cerebrovascular hemodynamics and homeostasis. OBJECTIVE Evaluate clinical, radiological patterns and prognostic factors of subarachnoid hemorrhage (SAH) patients according to age. METHOD Three hundred and eighty nine patients with aneurismal SAH from a Brazilian tertiary institution (Hospital do Servidor Público Estadual de São Paulo) were consecutively evaluated from 2002 to 2012 according to Fisher and Hunt Hess classifications and Glasgow Outcome Scale. RESULTS There was statistically significant association of age with impaired clinical, radiological presentation and outcomes in cases of SAH. CONCLUSION Natural course of SAH is worse in elderly patients and thus, proper recognition of the profile of such patients and their outcome is necessary to propose standard treatment.
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Affiliation(s)
- Felix Hendrik Pahl
- Departamento de Neurocirurgia, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
| | | | - José Marcus Rotta
- Departamento de Neurocirurgia, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
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2026
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Bacigaluppi S, Zona G, Secci F, Spena G, Mavilio N, Brusa G, Agid R, Krings T, Ottonello G, Fontanella M. Diagnosis of cerebral vasospasm and risk of delayed cerebral ischemia related to aneurysmal subarachnoid haemorrhage: an overview of available tools. Neurosurg Rev 2015; 38:603-18. [DOI: 10.1007/s10143-015-0617-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 11/16/2014] [Indexed: 01/01/2023]
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2027
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Heffren J, McIntosh AM, Reiter PD. Nimodipine for the prevention of cerebral vasospasm after subarachnoid hemorrhage in 12 children. Pediatr Neurol 2015; 52:356-60. [PMID: 25585913 DOI: 10.1016/j.pediatrneurol.2014.11.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 11/02/2014] [Accepted: 11/05/2014] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Subarachnoid hemorrhage is a rare, but life-threatening neurological emergency. Cerebral vasospasm is a complication of subarachnoid hemorrhage that contributes significantly to morbidity and mortality. Nimodipine has been used in adults to reduce the incidence of cerebral vasospasm after subarachnoid hemorrhage and improve long-term outcomes. There are, however, no data in children. METHODS Records of children with a confirmed diagnosis of subarachnoid hemorrhage who received nimodipine between January 1, 2005 and August 31, 2013 were reviewed. Dosing of nimodipine and associated hypotensive events were recorded. Transcranial Doppler ultrasonography, cranial computerized tomography, and angiography were followed as a measure of cerebral vasospasm, rebleeding, and subsequent infarction. RESULTS Twelve children (average age 11.8 ± 3.3 years, age range 3.5 to 17.3 years) were included. Aneurysm was responsible for the highest percentage (41.7%) of subarachnoid hemorrhage events. The mean dose of oral nimodipine was 1 mg/kg every 4 hours and was associated with a high rate of hypotension requiring intervention or dose modification. Clinical outcomes while on nimodipine therapy varied; evidence of vasospasm was observed in 67%, new infarction in 33%, and rebleeding in 17%. Functional and cognitive deficits were minor in two-thirds and absent in the remaining individuals. All patients survived until hospital discharge. CONCLUSIONS Oral nimodipine after subarachnoid hemorrhage in children does not eliminate vasospasm, rebleeding, or infarction and is associated with significant hypotension. Nevertheless, clinical outcomes appear favorable relative to the adult population who receive nimodipine. Further study, with dose titration, is warranted.
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Affiliation(s)
- Josh Heffren
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington
| | - Angela M McIntosh
- Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado
| | - Pamela D Reiter
- Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado; Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, Aurora, Colorado.
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2028
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Dhandapani S, Goudihalli S, Mukherjee KK, Singh H, Srinivasan A, Danish M, Mahalingam S, Dhandapani M, Gupta SK, Khandelwal N, Mathuriya SN. Prospective study of the correlation between admission plasma homocysteine levels and neurological outcome following subarachnoid hemorrhage: a case for the reverse epidemiology paradox? Acta Neurochir (Wien) 2015; 157:399-407. [PMID: 25510646 DOI: 10.1007/s00701-014-2297-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 11/28/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Homocysteine (tHcy) has been known over the last few decades for its putative impact on vascular diseases, but has not been evaluated much in patients with subarachnoid hemorrhage (SAH). This study was carried out to assess its prognostic impact on the neurological outcome following SAH. METHODS Admission plasma tHcy was evaluated in 90 SAH patients and prospectively studied in relation to various factors and the Glasgow Outcome Scale (GOS) at 3 months. Univariate and multivariate analyses were performed using SPSS 21. RESULTS tHcy was significantly higher following SAH compared to matched controls [median (IQR): 25.7 (17.3-35.9) vs. 14.0 (9.8-17.6) μmol/l, p < 0.001]. It was significantly higher in younger patients. However, systemic disease, WFNS and Fisher grades did not have a significant impact on its levels. tHcy was significantly lower among patients who died [median (IQR): 16.0 (14.4-20.6) vs. 29.7 (21.8-40.2) μmol/l, p < 0.001] and those with unfavorable outcome (GOS 1-3) [median (IQR): 21.6 (14.5-28.2) vs. 30.3 (20.4-40.7) μmol/l, p = 0.004] compared to others, with a significant continuous positive correlation between tHcy and GOS (p = 0.002). The beneficial association of tHcy with outcome was homogeneous with no significant subgroup difference. Multivariate analysis using binary logistic regression adjusting for the effects of age, systemic disease, WFNS grade, Fisher grade, site of aneurysm, clipping or coiling revealed higher tHcy to have a significant independent association with both survival (p = 0.01) and favorable outcome (p = 0.04). CONCLUSIONS Higher homocysteine levels following SAH appear to have a significant association with both survival and favorable neurological outcome, independent of other known prognostic factors, apparently exemplifying "reverse epidemiology paradox" in which a conventional risk factor seems to impart a survival advantage.
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Affiliation(s)
- Sivashanmugam Dhandapani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India,
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2029
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Cho SY, Lee DH, Shin HS, Lee SH, Koh JS, Jung WS, Moon SK, Park JM, Ko CN, Kim H, Park SU. The efficacy and safety of acupuncture for cerebral vasospasm after subarachnoid hemorrhage: study protocol for a randomized controlled trial. Trials 2015; 16:68. [PMID: 25886483 PMCID: PMC4352281 DOI: 10.1186/s13063-015-0591-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 02/06/2015] [Indexed: 11/10/2022] Open
Abstract
Background Subarachnoid hemorrhage (SAH) is a neurological disease with a high mortality rate. Several serious complications frequently arise after successful surgery for this condition. Cerebral vasospasm, one such complication, occurs in 50 to 70% of SAH patients. These patients suffer neurological symptoms known as delayed ischemic neurological deficit (DIND); however, the effect of treatment of vasospasm is limited. The major pathogenesis of cerebral vasospasm is the reduction of nitric oxide (NO) and activation of vasoconstrictors. Acupuncture is known to increase the production and activity of vascular endothelial cell-derived NO and improve endothelium-dependent vasodilatation. A preliminary retrospective case study to investigate the ability of acupuncture to prevent the occurrence of cerebral vasospasm has been conducted. However, no randomized, controlled clinical trials have been carried out to evaluate the efficacy of acupuncture for cerebral vasospasm. Methods/Design This trial will be a single-center, randomized, placebo-controlled, parallel group, patient-assessor-blinded clinical trial. A total of 80 patients with SAH will be randomized into two groups: a study group given acupuncture, electroacupuncture, and intradermal acupuncture, and a control group given mock transcutaneous electrical nerve stimulation and sham intradermal acupuncture. Intervention will start within 96 h after SAH, and a total of 12 sessions will be performed during a 2-week period. The primary outcome measure will be the occurrence of DIND, and the secondary outcomes will be vasospasm as measured by cerebral angiography, transcranial Doppler, clinical symptoms, vasospasm-related infarcts, NO and endothelin-1 plasma levels, mortality, and modified Rankin Scale scores. Discussion This trial will examine the efficacy and safety of acupuncture for cerebral vasospasm after SAH. The placebo effect will be excluded and the mechanism of action of the treatments will be evaluated through blood testing. Trial registration ClinicalTrials.gov NCT02275949, Registration date: 26 October 2014.
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Affiliation(s)
- Seung-Yeon Cho
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Dong-Hyuk Lee
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Hee Sup Shin
- Department of Neurosurgery, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Seung Hwan Lee
- Department of Neurosurgery, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Jun Seok Koh
- Department of Neurosurgery, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Woo-Sang Jung
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Sang-Kwan Moon
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Jung-Mi Park
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Chang-Nam Ko
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Ho Kim
- Department of Epidemiology and Biostatistics, Graduate School of Public Health & Institute of Health and Environment, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742, Republic of Korea.
| | - Seong-Uk Park
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea. .,Stroke & Neurological Disorders Center, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, Republic of Korea.
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2030
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Serrone JC, Maekawa H, Tjahjadi M, Hernesniemi J. Aneurysmal subarachnoid hemorrhage: pathobiology, current treatment and future directions. Expert Rev Neurother 2015; 15:367-80. [PMID: 25719927 DOI: 10.1586/14737175.2015.1018892] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aneurysmal subarachnoid hemorrhage is the most devastating form of stroke. Many pathological mechanisms ensue after cerebral aneurysm rupture, including hydrocephalus, apoptosis of endothelial cells and neurons, cerebral edema, loss of blood-brain barrier, abnormal cerebral autoregulation, microthrombosis, cortical spreading depolarization and macrovascular vasospasm. Although studied extensively through experimental and clinical trials, current treatment guidelines to prevent delayed cerebral ischemia is limited to oral nimodipine, maintenance of euvolemia, induction of hypertension if ischemic signs occur and endovascular therapy for patients with continued ischemia after induced hypertension. Future investigations will involve agents targeting vasodilation, anticoagulation, inhibition of apoptosis pathways, free radical neutralization, suppression of cortical spreading depolarization and attenuation of inflammation.
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Affiliation(s)
- Joseph C Serrone
- Department of Neurosurgery, Töölö Hospital, University of Helsinki, Topeliuksenkatu 5, PO Box 266, 00029 HUS, Helsinki, Finland
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2031
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Schoen JC, Campbell RL, Sadosty AT. Headache in pregnancy: an approach to emergency department evaluation and management. West J Emerg Med 2015; 16:291-301. [PMID: 25834672 PMCID: PMC4380381 DOI: 10.5811/westjem.2015.1.23688] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 12/11/2014] [Accepted: 01/09/2015] [Indexed: 12/24/2022] Open
Abstract
Headache is a common presenting complaint in the emergency department. The differential diagnosis is broad and includes benign primary causes as well as ominous secondary causes. The diagnosis and management of headache in the pregnant patient presents several challenges. There are important unique considerations regarding the differential diagnosis, imaging options, and medical management. Physiologic changes induced by pregnancy increase the risk of cerebral venous thrombosis, dissection, and pituitary apoplexy. Preeclampsia, a serious condition unique to pregnancy, must also be considered. A high index of suspicion for carbon monoxide toxicity should be maintained. Primary headaches should be a diagnosis of exclusion. When advanced imaging is indicated, magnetic resonance imaging (MRI) should be used, if available, to reduce radiation exposure. Contrast agents should be avoided unless absolutely necessary. Medical therapy should be selected with careful consideration of adverse fetal effects. Herein, we present a review of the literature and discuss an approach to the evaluation and management of headache in pregnancy
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Affiliation(s)
- Jessica C Schoen
- Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Ronna L Campbell
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - Annie T Sadosty
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
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2032
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Abstract
Cerebral vasospasm causes delayed ischemic neurologic deficits after aneurysmal subarachnoid hemorrhage. This is a well-established clinical entity with significant associated morbidity and mortality. The underlying patholphysiology is highly complex and poorly understood. Large-vessel vasospasm, autoregulatory dysfunction, inflammation, genetic predispositions, microcirculatory failure, and spreading cortical depolarization are aspects of delayed neurologic deterioration that have been described in the literature. This article presents a perspective on cerebral vasospasm, as guided by the literature to date, specifically examining the mechanism, diagnosis, and treatment of cerebral vasospasm.
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2033
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Bunevicius A, Iervasi G, Bunevicius R. Neuroprotective actions of thyroid hormones and low-T3 syndrome as a biomarker in acute cerebrovascular disorders. Expert Rev Neurother 2015; 15:315-26. [DOI: 10.1586/14737175.2015.1013465] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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2034
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Kai H. [Hypertension: The Points of Management of Hypertensions--Based on the JSH 2014 Hypertension Guidelines--. Topics: IV. Treatment for hypertension associated with cerebrovascular disease/heart disease]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2015; 104:232-239. [PMID: 26571701 DOI: 10.2169/naika.104.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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2035
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Tholance Y, Barcelos GK, Dailler F, Renaud B, Marinesco S, Perret-Liaudet A. Biochemical neuromonitoring of poor-grade aneurysmal subarachnoid hemorrhage: comparative analysis of metabolic events detected by cerebral microdialysis and by retrograde jugular vein catheterization. Neurol Res 2015; 37:578-87. [PMID: 25668478 DOI: 10.1179/1743132815y.0000000012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES In severe aneurysmal subarachnoid hemorrhage (aSAH), pathological changes in cerebral energy metabolism can be detected either by local measurements using cerebral microdialysis (cMD) together with brain tissue oxygen probe or by global measurements of arterio-jugular difference performed with retrograde jugular vein catheter. Our main objective was to compare the two methods of detection and assess whether combining biomarkers from both procedures could improve outcome prediction, which has never been studied before. METHODS This study included 400 sets of paired arterial and jugular venous samples and 3138 brain microdialyzates obtained from 18 poor-grade aSAH patients. Using Glasgow outcome scale (GOS), neurochemical data from unfavorable (GOS 1-3) and favorable (GOS 4-5) outcome groups were compared. RESULTS The lactate/pyruvate ratio was found as the most sensitive marker for predicting unfavorable outcome (90%), although not specific. In contrast, hypoxic lactate events and those of metabolic ratio (MR) < 3.44, most frequently observed in the unfavorable outcome group than in the favorable one (13.9 vs 0.9% and 33.3 vs 3.75% respectively), were shown to be more specific biomarkers (86%) to predict unfavorable outcome, but less sensitive ( < 70%). The combination of these three biomarkers improved the accuracy of outcome prediction (sensitivity 90% and specificity 71%). DISCUSSION Both retrograde jugular venous catheterization (RJVC) and cMD contribute to monitor poor-grade aSAH patients. In this preliminary study, we show that these two techniques are complementary and their combination increases the accuracy of outcome prediction.
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2036
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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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2037
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2038
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Vivancos J, Gilo F, Frutos R, Maestre J, García-Pastor A, Quintana F, Ximénez-Carrillo Á. Clinical practice guidelines for subarachnoid haemorrhage. Diagnosis and treatment. Neurologia 2015; 31:649-650. [PMID: 25649194 DOI: 10.1016/j.nrl.2014.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 10/09/2014] [Indexed: 11/29/2022] Open
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2039
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Graffeo CS, Tanweer O, Nieves CF, Belmont HM, Izmirly PM, Becske T, Huang PP. Rapid aneurysm growth and rupture in systemic lupus erythematosus. Surg Neurol Int 2015; 6:9. [PMID: 25657862 PMCID: PMC4310132 DOI: 10.4103/2152-7806.149617] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 11/02/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) due to intracranial aneurysm rupture is a major neurosurgical emergency associated with significant morbidity and mortality. Rapid aneurysm growth is associated with rupture. Systemic lupus erythematosus (SLE) is a multi-system autoimmune disorder whose complications can include cerebral vasculitis and vasculopathy. Intracranial aneurysms are not known to occur more frequently in SLE patients than the general population; however, aneurysm growth rates have not been studied in SLE. CASE DESCRIPTION We present a 43-year-old female with SLE on prednisone, hydroxychloroquine, and azathioprine with moderate disease activity who presented with severe, acute-onset headache and was found to have Hunt and Hess grade II SAH due to rupture of an 8 mm saccular anterior communicating artery (ACoA) aneurysm. The patient developed severe vasospasm, re-ruptured, and was taken for angiography and embolization, which was challenging due to a high degree of vasospasm and arterial stenosis. Review of imaging from less than 2 years prior demonstrated a normal ACoA complex without evidence of an aneurysm. CONCLUSION We review the literature and discuss the risk factors and pathophysiology of rapid aneurysm growth and rupture, as well as the pathologic vascular changes associated with SLE. Although SLE patients do not develop intracranial aneurysm at an increased rate, these changes may predispose them to higher incidence of growth and rupture. This possibility-coupled with increased morbidity and mortality of SAH in SLE-suggests that SAH should be considered in SLE patients presenting with headache, and advocates for more aggressive treatment of SLE patients with unruptured aneurysms.
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Affiliation(s)
| | - Omar Tanweer
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Cesar Fors Nieves
- Department of Division of Rheumatology, New York University School of Medicine, New York, USA
| | - H Michael Belmont
- Department of Division of Rheumatology, New York University School of Medicine, New York, USA
| | - Peter M Izmirly
- Department of Division of Rheumatology, New York University School of Medicine, New York, USA
| | - Tibor Becske
- Department of Radiology, New York University School of Medicine, New York, USA ; Department of Neurology, New York University School of Medicine, New York, USA
| | - Paul P Huang
- Department of Neurosurgery, New York University School of Medicine, New York, USA
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2040
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Tekle WG, Chaudry SA, Hassan AE, Qaiser H, Grigoryan M, Rodriguez GJ, Qureshi AI. High risk of new episode of symptomatic vasospasm in unaffected arteries in subarachnoid hemorrhage patients receiving targeted endovascular treatment for symptomatic focal vasospasm. Neurocrit Care 2015; 20:399-405. [PMID: 23463421 DOI: 10.1007/s12028-013-9825-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is controversy whether asymptomatic vasospasm in other arteries should be concurrently treated (global treatment) in patients receiving targeted endovascular treatment [percutaneous-transluminal-angioplasty (PTA) and/or intra-arterial (IA) vasodilators] for focal symptomatic vasospasm. OBJECTIVE To determine the rates of occurrence of new symptomatic vasospasm in previously asymptomatic arterial distributions among patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent targeted endovascular treatment for focal symptomatic vasospasm. METHODS We identified all patients with SAH who had received targeted endovascular treatment during a 4-year period. We ascertained any new occurrence of symptomatic vasosopasm requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the same hospitalization. Blinded reviewers quantitatively graded angiographic vasospasm (<25, 26-49, ≥50 %) in all major arteries for each patient at the time of targeted treatment. RESULTS Of the 41 patients who received targeted endovascular treatment (PTA in 41 % and vasodilators in 59 %), 11 (27 %) developed new symptomatic vasospasm in previously asymptomatic vascular distributions requiring endovascular treatment. Moderate severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment tended to predict the occurrence of new symptomatic vasospasm. The rate of death and disability at discharge [modified Rankin scale (mRS) of 3-6] was 82 % (9/11) among those who developed a new episode of symptomatic vasospasm compared with 70 % (21/30) in those who did not (P = 0.58). CONCLUSIONS High risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global endovascular treatment during the initial targeted endovascular treatment session.
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Affiliation(s)
- Wondwossen G Tekle
- Zeenat Qureshi Stroke Research Center and Department of Neurology, University of Minnesota, 420 Delaware St. SE. MMC 295, Minneapolis, MN, 55455, USA,
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2041
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The utility of serum procalcitonin in distinguishing systemic inflammatory response syndrome from infection after aneurysmal subarachnoid hemorrhage. Neurocrit Care 2015; 20:375-81. [PMID: 24522762 DOI: 10.1007/s12028-014-9960-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Systemic inflammatory response syndrome (SIRS) occurs frequently after aneurysmal subarachnoid hemorrhage (aSAH). It is a clinical challenge to distinguish between SIRS and incipient infection. Procalcitonin (PCT) has been studied among general critical care patients as a biomarker for infection. We hypothesized that PCT could be useful to distinguish SIRS from sepsis in aSAH patients. METHODS Prospective, observational study conducted in the multidisciplinary intensive care unit at Mayo Clinic, Jacksonville, FL between August 2009 and September 2010. Main predictor was serum PCT obtained on admission and with subsequent episodes of SIRS. A level of 0.2 ng/mL or higher was considered as elevated PCT. Main outcome was clinical infection, which was subsequently subcategorized into major (systemic) and minor (localized) infections in the sensitivity analysis. RESULTS Forty consecutive patients were enrolled. Majority (88 %) developed SIRS during the hospitalization. Infection developed in 16 (40 %) patients, with 6 patients meeting criteria for major infection. Overall, PCT was found to be highly specific for all infections and the subcategory of major infections (97 and 93 %, respectively) with related high negative predictive values. Odds ratio for elevated PCT with clinical infections ranged from 25.2 (95 % CI 2.7-233) to 33.3 (95 % CI 4.3-261) for all and major infections, respectively. Related receiver operating characteristic curves for elevated PCT were 0.74 and 0.96 for all and major infections, respectively. CONCLUSIONS Procalcitonin of 0.2 ng/mL or greater was demonstrated to be very specific for sepsis among patients with aSAH. Further studies should validate this result and establish its clinical applicability.
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2042
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Stapleton CJ, Walcott BP, Fusco MR, Butler WE, Thomas AJ, Ogilvy CS. Surgical Management of Ruptured Middle Cerebral Artery Aneurysms With Large Intraparenchymal or Sylvian Fissure Hematomas. Neurosurgery 2015; 76:258-64; discussion 264. [DOI: 10.1227/neu.0000000000000596] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Abstract
BACKGROUND:
Craniotomy for hematoma evacuation and aneurysm clipping is the treatment modality of choice for ruptured middle cerebral artery (MCA) aneurysms with intracranial hematomas. Recent literature suggests that endovascular coil embolization followed by hematoma evacuation can be an acceptable alternative.
OBJECTIVE:
To determine neurological outcomes in patients with ruptured MCA aneurysms and intraparenchymal or sylvian fissure hematomas.
METHODS:
The records of 49 patients with ruptured MCA aneurysms with large intracranial hematomas treated with hematoma evacuation and aneurysm clipping between January 2000 and December 2013 were retrospectively reviewed.
RESULTS:
Within this cohort, 35 patients (71.4%) were Hunt and Hess grade IV or V on presentation. The mean hematoma volume was 100.4 ± 77.2 mL. Craniectomy was performed in 40 patients (81.6%). Angiographic vasospasm developed in 15 patients (30.6%). The in-hospital mortality rate was 28.6% (14 patients). At a mean of 25.3 ± 34.0 months follow-up, a good outcome (modified Rankin Scale [mRS] score 0–3) was observed in 18 patients (36.7%). Significant factors associated with poor outcome or death (mRS scores of 4–6) included increasing age (P < .01), increasing Hunt and Hess grade (P = .03), increasing modified Fisher grade (P = .01), presence of intraventricular hemorrhage (P < .01), decreasing percentage of hematoma evacuation (P < .05), need for craniectomy (P <. 01), need for external ventricular drainage (P = .04), and angiographic vasospasm (P = .02).
CONCLUSION:
MCA aneurysm rupture with concomitant large intraparenchymal or sylvian fissure hematoma formation carries a grave prognosis. Simultaneous hematoma evacuation and aneurysm clipping with or without craniectomy can be an effective treatment modality.
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Affiliation(s)
- Christopher J. Stapleton
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian P. Walcott
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Matthew R. Fusco
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Boston, Massachusetts
| | - William E. Butler
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ajith J. Thomas
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Boston, Massachusetts
| | - Christopher S. Ogilvy
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Boston, Massachusetts
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2043
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Wang CX, Lin YX, Xie GB, Shi JX, Zhou ML. Constriction and dysfunction of pial arterioles after regional hemorrhage in the subarachnoid space. Brain Res 2015; 1601:85-91. [PMID: 25598204 DOI: 10.1016/j.brainres.2015.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/05/2015] [Accepted: 01/08/2015] [Indexed: 11/17/2022]
Abstract
Increasing evidence indicates that poor outcomes after brain hemorrhage, especially after subarachnoid hemorrhage (SAH), can be attributed largely to dysfunction of the cerebral microcirculation. However, the cause of this dysfunction remains unclear. Here, we investigated changes in the cerebral microcirculation after regional hemorrhage in the subarachnoid space using the closed cranial window technique in mice. A single pial arteriole on the surface of the brain was punctured to induce a regional hemorrhage in the subarachnoid space. Physiological parameters were monitored during the procedure, and microvessel diameter was measured after hemorrhage. The vasoreactivity of the arterioles in response to hypercapnia as well as to topical application of the vasodilator acetylcholine (ACh) and S-nitroso-N-acetyl-penicillamine (SNAP) were assessed. The constriction of pial arterioles was detected without changes in other physiological parameters. Decreased reactivity of pial arterioles to all of the applied vasodilatory stimuli was observed after hemorrhage. Our results indicate that regional hemorrhage in the subarachnoid space can induce the vasospasm of microvessels and also reduce the vasoreactivity of pial arterioles.
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Affiliation(s)
- Chun-xi Wang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Yi-xing Lin
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Guang-bin Xie
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Ji-xin Shi
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Meng-liang Zhou
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China.
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2044
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Jaja BNR, Lingsma H, Schweizer TA, Thorpe KE, Steyerberg EW, Macdonald RL. Prognostic value of premorbid hypertension and neurological status in aneurysmal subarachnoid hemorrhage: pooled analyses of individual patient data in the SAHIT repository. J Neurosurg 2015; 122:644-52. [PMID: 25554825 DOI: 10.3171/2014.10.jns132694] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECT The literature has conflicting reports about the prognostic value of premorbid hypertension and neurological status in aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to investigate the prognostic value of premorbid hypertension and neurological status in the SAH International Trialists repository. METHODS Patient-level meta-analyses were conducted to investigate univariate associations between premorbid hypertension (6 studies; n = 7249), admission neurological status measured on the World Federation of Neurosurgical Societies (WFNS) scale (10 studies; n = 10,869), and 3-month Glasgow Outcome Scale (GOS) score. Multivariable analyses were performed to sequentially adjust for the effects of age, CT clot burden, aneurysm location, aneurysm size, and modality of aneurysm repair. Prognostic associations were estimated across the ordered categories of the GOS using proportional odds models. Nagelkerke's R(2) statistic was used to quantify the added prognostic value of hypertension and neurological status beyond those of the adjustment factors. RESULTS Premorbid hypertension was independently associated with poor outcome, with an unadjusted pooled odds ratio (OR) of 1.73 (95% confidence interval [CI] 1.50-2.00) and an adjusted OR of 1.38 (95% CI 1.25-1.53). Patients with a premorbid history of hypertension had higher rates of cardiovascular and renal comorbidities, poorer neurological status (p ≤ 0.001), and higher odds of neurological complications including cerebral infarctions, hydrocephalus, rebleeding, and delayed ischemic neurological deficits. Worsening neurological status was strongly independently associated with poor outcome, including WFNS Grades II (OR 1.85, 95% CI 1.68-2.03), III (OR 3.85, 95% CI 3.32-4.47), IV (OR 5.58, 95% CI 4.91-6.35), and V (OR 14.18, 95% CI 12.20-16.49). Neurological status had substantial added predictive value greater than the combined value of other prognostic factors (R(2) increase > 10%), while the added predictive value of hypertension was marginal (R(2) increase < 0.5%). CONCLUSIONS This study confirmed the strong prognostic effect of neurological status as measured on the WFNS scale and the independent but weak prognostic effect of premorbid hypertension. The effect of premorbid hypertension could involve multifactorial mechanisms, including an increase in the severity of initial bleeding, the rate of comorbid events, and neurological complications.
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2045
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Bokhari YA, Batarfi AH, Alnahdi YA, Almekhlafi MA, Baeesa SS. Aneurysmal subarachnoid hemorrhage affects the younger age groups in a Saudi academic center. Ann Saudi Med 2015; 35:36-40. [PMID: 26142936 PMCID: PMC6152555 DOI: 10.5144/0256-4947.2015.36] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The epidemiology, clinical characteristics, and risk factors of aneurysmal subarachnoid hemorrhage (aSAH) in Saudi Arabia are still largely unknown. This retrospective cohort study was aimed to determine these features of the disease. DESIGN AND SETTINGS A retrospective cohort review was performed on all patients with aSAH who were treated and followed at King Abdulaziz University Hospital between July 2000 and December 2013. PATIENTS AND METHODS A quantitative methodology was used and data were collected on patients' age, gender, nationality, time to hospital presentation, clinical presentation, aneurysm characteristics, treatment, complications, and outcome. RESULTS A total of 41 patients with aSAH were included with a mean age of 43.2 (11.5) years; and males comprised 34.1%. Smoking and hypertension were the most common risk factors. Eight patients had known risk factors for aSAH, and were diagnosed using CT scans. An unfavorable outcome was associated with the presence of vasospasm (P < .001), cerebral edema (P=.001), and hydrocephalus (P=.003). CONCLUSION A high occurrence of aSAH was observed in an age group younger than that reported in published reports. The pattern and outcome of aSAH were otherwise similar to prior reports. Future studies investigating these observations in other centers in the country can improve the prevention and treatment of this serious condition.
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Affiliation(s)
| | | | | | | | - Saleh S Baeesa
- Saleh S. Baeesa, MBChB, FRCSC, Division of Neurosurgery, Faculty of Medicine King Abdulaziz University, PO Box 80215, Jeddah 21589, Saudi Arabia, T: 012-6408346;, F: 02-6408347,
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2046
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Kapinos G. Redefining secondary injury after subarachnoid hemorrhage in light of multimodal advanced neuroimaging, intracranial and transcranial neuromonitoring: beyond vasospasm. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:259-267. [PMID: 25366634 DOI: 10.1007/978-3-319-04981-6_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The classic idea that arterial narrowing, called vasospasm (VSP), represents the hallmark of secondary injury after subarachnoid hemorrhage, has been challenged. The more complex and pleiotropic pathophysiological repercussions from the irruption of arterial blood into the subarachnoid layers go beyond the ascribed VSP. Putting adjectives in front of this term, such as "symptomatic," "microdialytic," or "angiographic" VSP, is misleading. Delayed cerebral ischemia (DCI) is a better term but remains restrictive to severe hypoperfusive injury and neglects oligemia, edema, and metabolic nonischemic injuries. In recognition of these issues, the international conference on VSP integrated "neurovascular events" into its name ( www.vasospasm2013.com ) and a multidisciplinary research group was formed in 2010 to study subgroups of DCI/VSP and their respective significance.In three parts, this tiered article provides a broader definitional envelope for DCI and secondary neurovascular insults after SAH, with a rubric for each subtype of delayed neuronal dysfunction. First, it pinpoints the need for nosologic precision and covers current terminological inconsistency. Then, it highlights the input of neuroimaging and neuromonitoring in defining secondary injurious processes. Finally, a new categorization of deteriorating patients is proposed, going beyond a hierarchical or dichotomized definition of VSP/DCI, and common data elements are suggested for future trials.
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Affiliation(s)
- Gregory Kapinos
- Department of Neurosurgery, North Shore-LIJ Health System, 300 Community Drive, Tower, 9th floor, Manhasset, NY, 11030, USA,
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2047
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Riordan MA, Kyle M, Dedeo C, Villwock MR, Bauer M, Vallano ML, Deshaies EM. Mild exercise reduces cerebral vasospasm after aneurysm subarachnoid hemorrhage: a retrospective clinical study and correlation with laboratory investigation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:55-61. [PMID: 25366600 DOI: 10.1007/978-3-319-04981-6_10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is a leading cause of death and disability and is often complicated by cerebral vasospasm (CV). Conventional management to prevent CV includes bedrest; however, inactivity places the patient at risk for nonneurological complications. We investigated the effect of mild exercise after SAH in clinical and laboratory settings. METHODS Clinical: Data from 80 patients with SAH were analyzed retrospectively. After aneurysms were secured, physical therapy was initiated as tolerated. CV and complications were compared by the timing of active physical therapy. Laboratory: 18 Rodents were divided into three groups: (1) control, (2) SAH without exercise, and (3) SAH plus mild exercise. On day 5, brainstems were removed and analyzed for the injury marker inducible nitric oxide synthase (iNOS). RESULTS Clinical: Mild exercise before day 4 significantly lowered the incidence of symptomatic CV compared with the nonexercised group. There was no difference in the incidence of additional complications based upon exercise. Laboratory: Staining for iNOS was significantly higher in the SAH group than the control group, but there was no difference between exercised and nonexercised SAH groups, confirming that exercise did not promote neuronal injury. CONCLUSION Early mobilization significantly reduced clinical CV. The relationship should be studied further in a prospective trial with defined exercise regimens.
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Affiliation(s)
- Margaret A Riordan
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
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2048
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Anesthesia for the surgical treatment of cerebral aneurysms☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543001-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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2049
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Sherif C, Wambacher B, Loyoddin M, Karaic R, Krafft P, Valentin A, Tscholakoff D, Kleinpeter G. Repeated combined endovascular therapy with milrinone and nimodipine for the treatment of severe vasospasm: preliminary results. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:203-207. [PMID: 25366625 DOI: 10.1007/978-3-319-04981-6_35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Delayed vasospasm (VSP) following aneurysmal subarachnoid hemorrhage (aSAH) remains a major source of morbidity. Milrinone was recently suggested as an invasive VSP treatment option. It is a phosphodiesterase III inhibitor with vasodilating and additional positive inotrope and anti-inflammatory effects. METHODS In this preliminary series, we included patients with severe VSP and unsuccessful maximum conservative therapy. Inclusion criteria were (1) transcranial Doppler (TCD) mean >180 cm/s; (2) increase of >50 % of TCD mean values within 6 h to values >150 cm/s; and/or (3) neurological deterioration (after exclusion of hemorrhage, hydrocephalus, and other systemic reasons). Patients received endovascular therapy with nimodipine 2 mg followed by milrinone 4-8 mg. Reinterventions were indicated aggressively in cases of persistent neurological deficits or persistent high mean TCD >180 cm/s. RESULTS Of 121 consecutive aSAH patients, 16 (13.2 %) received endovascular VSP therapy. Of these, 11 patients (68.5 %) received ≥ 3 interventions (median 4; maximum 9); 14 (87.5 %) showed postinterventional angiographic improvement of vessel diameters; and 11 (68.5 %) showed improvement of their neurological deficits after a mean follow-up time of 4.5 months. No cardiovascular adverse events attributed to milrinone were observed. CONCLUSIONS Milrinone may be a useful supplementary substance for endovascular VSP therapy. Aggressive reintervention indications did not cause additional adverse events.
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Affiliation(s)
- Camillo Sherif
- Department of Neurosurgery, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030, Vienna, Austria,
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2050
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Anestesia para el tratamiento quirúrgico de aneurismas cerebrales. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2014.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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