Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association

Aneurysmal subarachnoid haemorrhage from a neuroimaging perspective

Neuroimaging is a key element in the management of patients suffering from subarachnoid haemorrhage (SAH). In this article, we review the current literature to provide a summary of the existing neuroimaging methods available in clinical practice. Noncontrast computed tomography is highly sensitive in detecting subarachnoid blood, especially within 6 hours of haemorrhage. However, lumbar puncture should follow a negative noncontrast computed tomography scan in patients with symptoms suspicious of SAH. Computed tomography angiography is slowly replacing digital subtraction angiography as the first-line technique for the diagnosis and treatment planning of cerebral aneurysms, but digital subtraction angiography is still required in patients with diffuse SAH and negative initial computed tomography angiography. Delayed cerebral ischaemia is a common and serious complication after SAH. The modern concept of delayed cerebral ischaemia monitoring is shifting from modalities that measure vessel diameter to techniques focusing on brain perfusion. Lastly, evolving modalities applied to assess cerebral physiological, functional and cognitive sequelae after SAH, such as functional magnetic resonance imaging or positron emission tomography, are discussed. These new techniques may have the advantage over structural modalities due to their ability to assess brain physiology and function in real time. However, their use remains mainly experimental and the literature supporting their practice is still scarce.

Intravenous flat-detector computed tomography angiography for symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage

The study evaluated the diagnostic accuracy of intravenous flat-detector computed tomography (IV FDCT) angiography in assessing hemodynamically significant cerebral vasospasm in patients with subarachnoid hemorrhage (SAH) with digital subtraction angiography (DSA) as the reference. DSA and IV FDCT were conducted concurrently in patients suspected of having symptomatic cerebral vasospasm postoperatively. The presence and severity of vasospasm were estimated according to location (proximal versus distal). Vasospasm >50% was defined as having hemodynamic significance. Vasospasms <30% were excluded from this analysis to avoid spectrum bias. Twenty-nine patients (311 vessel segments) were measured. The intra- and interobserver agreements were excellent for depicting vasospasm (k = 0.84 and 0.74, resp.). IV FDCT showed a sensitivity of 95.7%, specificity of 92.3%, positive predictive value of 93.6%, and negative predictive value of 94.7% for detecting vasospasm (>50%) with DSA as the reference. Bland-Altman plots revealed good agreement of assessing vasospasm between the two tests. The discrepancy of vasospasm severity was more noted in the distal location with high-severity. However, it was not statistically significant (Spearman's rank test; r = 0.15, P = 0.35). Therefore, IV FDCT could be a feasible noninvasive test to evaluate suspected significant vasospasm in SAH.

Adverse events after unruptured cerebral aneurysm treatment: a single-center experience with clipping/coil embolization combined units

BACKGROUND

Indications of clipping (Clip) or coil embolization (Coil) for unruptured cerebral aneurysms (uAN) was not elaborated because prediction of rupture and risk of treatment are difficult. This study aims to determine the risk-benefit analysis of treating uAN by a comprehensive and retrospective investigation of the adverse events and sequelae in patients treated by our Clip/Coil combined units.

METHODS

Clip and Coil were performed in 141 and 80 patients, respectively; Clip for middle cerebral artery AN and Coil for paraclinoid or basilar apex AN. Worsening of modified Rankin scale or mini-mental state examination was defined as major morbidity. Minor morbidity or transient morbidity was defined as other neurologic deficits. Mortality and these morbidities were considered as serious adverse events. Convulsion or events outside the brain were defined as mild adverse events.

RESULTS

Total mortality and major morbidity were low. Incidence of serious adverse events was not significantly different between the Clip and Coil (17 patients [12.1%] and 6 patients [7.5%]), but the number of total adverse events was significantly different (32 patients [22.7%] in Clip vs. 8 patients [10.0%] in Coil). Because mild morbidities were significantly more frequent in the Clip (20 patients [14.2%]) compared with the Coil (2 patients [2.5%]). Convulsion occurred in 11 (7.8%) patients in the Clip but none in the Coil.

CONCLUSIONS

Our combined unit decreased the occurrence of mortality/major morbidity; however, minor adverse effects were common, especially in the Clip group because of many intrinsic problems of Clip itself. This result suggests further consideration for the treatment modality for uAN.

Incidence of and factors associated with manipulation of nimodipine dosage in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Aneurysmal subarachnoid hemorrhage is a significant cause of death and disability. Nimodipine 60 mg administered enterally every 4 h improves neurologic outcomes in these patients. However, hypotension is an adverse effect of nimodipine and is believed to prompt clinicians to prescribe an unproven, nonstandard nimodipine dosing regimen.

OBJECTIVES

The primary objective was to determine the prescribing incidence of a nonstandard nimodipine dosing regimen (30 mg every 2 h) after initial prescription of the standard dose (60 mg every 4 h). The secondary objective was to determine factors associated with this dosage change.

METHODS

This retrospective cohort study evaluated participants receiving nimodipine for aneurysmal subarachnoid hemorrhage at a tertiary care teaching hospital between October 2005 and December 2011. Univariate and multivariate regression analyses were performed to identify factors associated with dosage manipulation.

RESULTS

A total of 166 eligible patients were identified. For all of these patients, nimodipine 60 mg every 4 h was prescribed initially. Subsequently, 81 (49%) of the patients were switched to nimodipine 30 mg every 2 h, whereas 85 (51%) continued on the original dosage (nimodipine 60 mg every 4 h) for the duration of their treatment. Multivariate analysis revealed that occurrence of vasospasm (odds ratio [OR] 5.30, 95% confidence interval [CI] 2.08-13.47; p < 0.001) and exposure to vasopressor therapy (OR 3.29, 95% CI 1.27-8.50; p = 0.014) were associated with increased odds of receiving the nonstandard nimodipine regimen.

CONCLUSIONS

Half of patients for whom nimodipine was prescribed for aneurysmal subarachnoid hemorrhage were exposed to an unproven regimen. Vasospasm and exposure to vasopressor therapy were associated with higher odds of receiving the nonstandard regimen. Further research is needed to evaluate whether nimodipine 30 mg every 2 h is efficacious and safe for patients in this population.

Risk factors for early hemorrhagic complications after endovascular coiling of ruptured intracranial aneurysms

BACKGROUND AND PURPOSE

The risk factors of early hemorrhagic complications after endovascular coiling are not well-known. We identified the factors affecting early hemorrhagic complications, defined as any expansion or appearance of hemorrhage shown by head CT in the initial 48 hours after coiling.

MATERIALS AND METHODS

We retrospectively reviewed a series of 93 patients who underwent coiling for a ruptured saccular aneurysm between 2006 and 2012 at our hospital.

RESULTS

Five patients showed early hemorrhagic complications, and all involved an expansion of the existing intracerebral hematoma immediately after coiling. The associated risk factors were accompanying intracerebral hemorrhage at onset (P < .001), postoperative antiplatelet therapy (P < .001), and thromboembolic complications (P = .044). In the accompanying intracerebral hemorrhage group, the associated risk factors were postoperative antiplatelet therapy (P = .044) and earlier initiation of coiling (9.8 ± 6.5 versus 28.1 ± 24.0 hours, P = .023). Early hemorrhagic complications were significant risk factors for worse clinical outcome (modified Rankin Scale, 2.02 ± 2.21 versus 4.4 ± 2.30, P = .022). None of the 93 patients showed further hemorrhage after the initial 48 hours after coiling.

CONCLUSIONS

The accompanying intracerebral hemorrhage at onset, thromboembolic complications, postoperative antiplatelet therapy, and earlier initiation of coiling were the risk factors for early hemorrhagic complications.

Predictors of shunt dependency after aneurysmal subarachnoid hemorrhage: results of a single-center clinical trial

BACKGROUND

Hydrocephalus (HC) after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequel. Proper selection of patients in need of permanent cerebrospinal fluid (CSF) diversion is, however, not straightforward. The aim of this study was to identify predictors of CSF shunt dependency following aSAH.

METHODS

We re-analyzed data acquired from aSAH patients previously enrolled in a prospective, controlled single-center clinical trial in which shunt dependency was not one of the end points. In the present study patients were allocated into two groups: those receiving a shunt (here denoted as shunt dependent) and those not receiving a shunt, based on a clinical decision process. Predictors of shunt dependency were identified by applying uni- and multivariable analysis. We tested a set of predefined possible risk factors based on the results of the clinical trial, including the impact of CSF drainage volume exceeding 1,500 ml during the 1st week after ictus.

RESULTS

Ninety patients were included in the study. Significant predictors of shunt dependency were poor clinical grade at admission [odds ratio (OR) 4.7, 95% confidence interval (CI) 1.2-18.4], large amounts of subarachnoid blood (OR 3.8, 95% CI 1.0-14.0), large ventricular size on preoperative cerebral computer tomographic (CT) scans (OR 1.0, 95% CI 1.0-1.1), and CSF volume drainage exceeding 1,500 ml during the 1st week after the ictus (OR 16.3, 95% CI 4.0-67.1). Age ≥70 years, larger amounts of intraventricular blood, vertebrobasilar aneurysm, and endovascular treatment tended to increase the likelihood of receiving a shunt. Outcome was not significantly different between shunted and non-shunted patients.

CONCLUSIONS

In this cohort of patients with clinical grade aSAH at admission, larger amounts of subarachnoid blood and large ventricular size on preoperative cerebral CT, and CSF drainage in excess of 1,500 ml during the 1st week after the ictus were significant predictors of shunt dependency. Shunt dependency did not hamper outcome.

Subarachnoid hemorrhage induces an early and reversible cardiac injury associated with catecholamine release: one-week follow-up study

Introduction

The occurrence of cardiac dysfunction is common after subarachnoid hemorrhage (SAH) and was hypothesized to be related to the release of endogenous catecholamines. The aim of this prospective study was to evaluate the relationship between endogenous catecholamine and cardiac dysfunction at the onset and during the first week after SAH.

Methods

Forty consecutive patients admitted for acute SAH without known heart disease were included. Catecholamine plasma concentrations and transthoracic echocardiography (TTE) were documented on admission, on day 1 (D1), and day 7 (D7).

Results

At baseline, 24 patients had a World Federation of Neurosurgical Societies score (WFNS) of one or two; the remaining 16 had a WFNS between three and five. Twenty patients showed signs of cardiac dysfunction on admission, including six with left ventricle (LV) systolodiastolic dysfunction and 14 with pure LV diastolic dysfunction. On admission, norepinephrine, epinephrine, dopamine, B-type Natriuretic Peptide (BNP) and Troponin Ic (cTnI) plasmatic levels were higher in patients with the higher WFNS score and in patients with altered cardiac function (all P <0.05). Among patients with cardiac injury, heart function was restored within one week in 13 patients, while seven showed persistent LV diastolic dysfunction (P = 0.002). Plasma BNP, cTnI, and catecholamine levels exerted a decrease towards normal values between D1 and D7.

Conclusion

Our findings show that cardiac dysfunction seen early after SAH was associated with both a rapid and sustained endogenous catecholamine release and WFNS score. SAH-induced cardiac dysfunction was regressive over the first week and paralleled the normalization of catecholamine concentration.

Surgical recanalization of distal middle cerebral artery occlusion due to a coil migration during endovascular coil embolization: a case report

Coil migration into the parent artery during endovascular coil embolization is a rare, but life-threatening complication, which can induce thromboembolism and result in poor outcome. A 63-year-old man was referred to Chonbuk National University Hospital emergency center due to migration of a coil for a left middle cerebral artery bifurcation unruptured aneurysm. We performed an emergency craniectomy to remove the coil migrated to the distal M2 branch and thrombus, and aneurysmal neck clipping for his aneurysm. Fortunately, at the six month follow-up, the patient did not show any noticeable neurological sequela. In case of parent artery occlusion due to coil migration an immediate recanalization should be performed by a neurovascular specialist who can provide both surgical treatment and endovascular management in order to prevent severe sequela or even death.

Double inversion recovery MR sequence for the detection of subacute subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The diagnosis of subacute subarachnoid hemorrhage is important because rebleeding may occur with subsequent life-threatening hemorrhage. Our aim was to determine the sensitivity of the 3D double inversion recovery sequence compared with CT, 2D and 3D FLAIR, 2D T2*, and 3D SWI sequences for the detection of subacute SAH.

MATERIALS AND METHODS

This prospective study included 25 patients with a CT-proved acute SAH. Brain imaging was repeated between days 14 and 16 (mean, 14.75 days) after clinical onset and included MR imaging (2D and 3D FLAIR, 2D T2*, SWI, and 3D double inversion recovery) after CT (median delay, 3 hours; range, 2-5 hours). A control group of 20 healthy volunteers was used for comparison. MR images and CT scans were analyzed independently in a randomized order by 3 blinded readers. For each subject, the presence or absence of hemorrhage was assessed in 4 subarachnoid areas (basal cisterns, Sylvian fissures, interhemispheric fissure, and convexity) and in brain ventricles. The diagnosis of subacute SAH was defined by the presence of at least 1 subarachnoid area with hemorrhage.

RESULTS

For the diagnosis of subacute SAH, the double inversion recovery sequence had a higher sensitivity compared with CT (P < .001), 2D FLAIR (P = .005), T2* (P = .02), SWI, and 3D FLAIR (P = .03) sequences. Hemorrhage was present for all patients in the interhemispheric fissure on double inversion recovery images, while no signal abnormality was noted in healthy volunteers. Interobserver agreement was excellent with double inversion recovery.

CONCLUSIONS

Our study showed that the double inversion recovery sequence has a higher sensitivity for the detection of subacute SAH than CT, 2D or 3D FLAIR, 2D T2*, and SWI.

Effects of intravenous infusion of hydrogen-rich fluid combined with intra-cisternal infusion of magnesium sulfate in severe aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

Background

The failures of recent studies intended to prevent cerebral vasospasm have moved the focus of research into delayed cerebral ischemia away from cerebral artery constriction towards other mechanisms. Recent accumulating evidence has suggested that early brain injury is also involved in the development of delayed cerebral ischemia, and that hydrogen can prevent early brain injury. Therefore, we have established a combination therapy of intravenous hydrogen infusion and intra-cisternal magnesium sulfate infusion for the treatment of both early brain injury and cerebral vasospasm. The present randomized controlled clinical trial is designed to investigate the effects of this novel therapeutic strategy on the occurrence of cerebral vasospasm, delayed cerebral ischemia, and clinical outcomes after high-grade subarachnoid hemorrhage.

Methods

This study is a randomized, double-blind, placebo-controlled design to be conducted in two hospitals. A total of 450 patients with high-grade subarachnoid hemorrhage will be randomized to one of three arms: (i) Mg + H₂ group, (ii) Mg group, and (iii) control group. Patients who are assigned to the Mg + H₂ group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous hydrogen-rich fluid infusion (200 mL) twice a day for 14 days. Patients who are assigned to the Mg group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Patients who are assigned to the control group will receive intra-cisternal Ringer solution without magnesium sulfate at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Primary outcome measures will be occurrence of delayed cerebral ischemia and cerebral vasospasm. Secondary outcome measures will be modified Rankin scale score at 3, 6, and 12 months and biochemical markers.

Discussion

The present protocol for a randomized, placebo-controlled study of intravenous hydrogen therapy with intra-cisternal magnesium infusion is expected to establish the efficacy and safety of this therapeutic strategy.

Trial registration

UMIN-CTR: UMIN000014696

Effects of tight computerized glucose control on neurological outcome in severely brain injured patients: a multicenter sub-group analysis of the randomized-controlled open-label CGAO-REA study

Introduction

Hyperglycemia is a marker of poor prognosis in severe brain injuries. There is currently little data regarding the effects of intensive insulin therapy (IIT) on neurological recovery.

Methods

A sub-group analysis of the randomized-controlled CGAO-REA study (NCT01002482) in surgical intensive care units (ICU) of two university hospitals. Patients with severe brain injury, with an expected ICU length of stay ≥48 hours were included. Patients were randomized between a conventional glucose management group (blood glucose target between 5.5 and 9 mmol.L⁻¹) and an IIT group (blood glucose target between 4.4 and 6 mmol.L⁻¹). The primary outcome was the day-90 neurological outcome evaluated with the Glasgow outcome scale.

Results

A total of 188 patients were included in this analysis. In total 98 (52%) patients were randomized in the control group and 90 (48%) in the IIT group. The mean Glasgow coma score at baseline was 7 (±4). Patients in the IIT group received more insulin (130 (68 to 251) IU versus 74 (13 to 165) IU in the control group, P = 0.01), had a significantly lower morning blood glucose level (5.9 (5.1 to 6.7) mmol.L⁻¹ versus 6.5 (5.6 to 7.2) mmol.L⁻¹, P <0.001) in the first 5 days after ICU admission. The IIT group experienced more episodes of hypoglycemia (P <0.0001). In the IIT group 24 (26.6%) patients had a favorable neurological outcome (good recovery or moderate disability) compared to 31 (31.6%) in the control group (P = 0.4). There were no differences in day-28 mortality. The occurrence of hypoglycemia did not influence the outcome.

Conclusions

In this sub-group analysis of a large multicenter randomized trial, IIT did not appear to alter the day-90 neurological outcome or ICU morbidity in severe brain injured patients or ICU morbidity.

Clinical practice guideline for the management of intracranial aneurysms

Purpose

An intracranial aneurysm, with or without subarachnoid hemorrhage (SAH), is a relevant health problem. The rupture of an intracranial aneurysm is a critical concern for individual health; even an unruptured intracranial aneurysm is an anxious condition for the individual. The aim of this guideline is to present current and comprehensive recommendations for the management of intracranial aneurysms, with or without rupture.

Materials and Methods

We performed an extensive literature search, using Medline. We met in person to discuss recommendations. This document is reviewed by the Task Force Team of the Korean Society of Interventional Neuroradiology (KSIN).

Results

We divided the current guideline for ruptured intracranial aneurysms (RIAs) and unruptured intracranial aneurysms (UIAs). The guideline for RIAs focuses on diagnosis and treatment. And the guideline for UIAs focuses on the definition of a high-risk patient, screening, principle for treatment and selection of treatment method.

Conclusion

This guideline provides practical, evidence-based advice for the management of patients with an intracranial aneurysm, with or without rupture.

Cost-effectiveness of CT angiography and perfusion imaging for delayed cerebral ischemia and vasospasm in aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Delayed cerebral ischemia and vasospasm are significant complications following SAH leading to cerebral infarction, functional disability, and death. In recent years, CTA and CTP have been used to increase the detection of delayed cerebral ischemia and vasospasm. Our aim was to perform comparative-effectiveness and cost-effectiveness analyses evaluating CTA and CTP for delayed cerebral ischemia and vasospasm in aneurysmal SAH from a health care payer perspective.

MATERIALS AND METHODS

We developed a decision model comparing CTA and CTP with transcranial Doppler sonography for detection of vasospasm and delayed cerebral ischemia in SAH. The clinical pathways were based on the "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association" (2012). Outcome health states represented mortality and morbidity according to functional outcomes. Input probabilities of symptoms and serial test results from CTA and CTP, transcranial Doppler ultrasound, and digital subtraction angiography were directly derived from an SAH cohort by using a multinomial logistic regression model. Expected benefits, measured as quality-adjusted life years, and costs, measured in 2012 US dollars, were calculated for each imaging strategy. Univariable, multivariable, and probabilistic sensitivity analyses were performed to determine the independent and combined effect of input parameter uncertainty.

RESULTS

The transcranial Doppler ultrasound strategy yielded 13.62 quality-adjusted life years at a cost of $154,719. The CTA and CTP strategy generated 13.89 quality-adjusted life years at a cost of $147,097, resulting in a gain of 0.27 quality-adjusted life years and cost savings of $7622 over the transcranial Doppler ultrasound strategy. Univariable and multivariable sensitivity analyses indicated that results were robust to plausible input parameter uncertainty. Probabilistic sensitivity analysis results yielded 96.8% of iterations in the right lower quadrant, representing higher benefits and lower costs.

CONCLUSIONS

Our model results suggest that CTA and CTP are the preferred imaging strategy in SAH, compared with transcranial Doppler ultrasound, leading to improved clinical outcomes and lower health care costs.

Subarachnoid hemorrhage in a patient taking phentermine for weight loss

OBJECTIVE

To report the case of an angiography-negative subarachnoid hemorrhage (SAH) in association with increased use of the sympathomimetic phentermine.

SUMMARY

A 45-year-old woman taking phentermine for weight loss presented with the "worst headache of her life," as well as nausea and some confusion. Her prior medical history was largely negative for pathology except for a 20-pack-year history of smoking.

RESULTS

Upon admission to an inpatient facility, the patient was normotensive with a Glasgow Coma Score of 15. She was found on computed tomography to have a diffuse SAH (Hunt and Hess grade 2, Fisher grade 3). Digital subtraction angiography, performed on hospital day 2, was negative for aneurysm. The patient convalesced in the intensive care unit for 8 days and was treated as a typical patient with SAH (i.e., vasospasm prophylaxis with nimodipine and atorvastatin, ad lib diet with strict attention to fluid balance to maintain euvolemia). A repeat angiographic study on hospital day 8 also did not reveal an aneurysm or other cause for her SAH. She was discharged thereafter with intensive smoking cessation education and counseled to discontinue phentermine. Upon follow-up 6 weeks later, the patient was without complaints or neurologic deficits and had resumed her previous activities and work.

CONCLUSION

Phentermine is a sympathomimetic agent found commonly in weight-loss products. Sympathomimetics have been linked to the development of hypertension, which can lead to cardiovascular and neurologic hemorrhages. We believe that the SAH in this patient was likely secondary to drug-induced hypertension or vasculopathy from the phentermine.

The 'Sphere': A Dedicated Bifurcation Aneurysm Flow-Diverter Device

We present flow-based results from the early stage design cycle, based on computational modeling, of a prototype flow-diverter device, known as the 'Sphere', intended to treat bifurcation aneurysms of the cerebral vasculature. The device is available in a range of diameters and geometries and is constructed from a single loop of NITINOL^® wire. The 'Sphere' reduces aneurysm inflow by means of a high-density, patterned, elliptical surface that partially occludes the aneurysm neck. The device is secured in the healthy parent vessel by two armatures in the shape of open loops, resulting in negligible disruption of parent or daughter vessel flow. The device is virtually deployed in six anatomically accurate bifurcation aneurysms: three located at the Basilar tip and three located at the terminus bifurcation of the Internal Carotid artery (at the meeting of the middle cerebral and anterior cerebral arteries). Both steady state and transient flow simulations reveal that the device presents with a range of aneurysm inflow reductions, with mean flow reductions falling in the range of 30.6-71.8% across the different geometries. A significant difference is noted between steady state and transient simulations in one geometry, where a zone of flow recirculation is not captured in the steady state simulation. Across all six aneurysms, the device reduces the WSS magnitude within the aneurysm sac, resulting in a hemodynamic environment closer to that of a healthy vessel. We conclude from extensive CFD analysis that the 'Sphere' device offers very significant levels of flow reduction in a number of anatomically accurate aneurysm sizes and locations, with many advantages compared to current clinical cylindrical flow-diverter designs. Analysis of the device's mechanical properties and deployability will follow in future publications.

Insurance status is associated with treatment allocation and outcomes after subarachnoid hemorrhage

OBJECTIVE

Subarachnoid hemorrhage (SAH) is a particularly devastating type of stroke which is responsible for one third of all stroke-related years of potential life lost before age 65. Surgical treatment has been shown to decrease both morbidity and mortality after subarachnoid hemorrhage. We hypothesized that payer status other than private insurance is associated with lower allocation to surgical treatment for patients with SAH and worse outcomes.

DESIGN

We examined the association between insurance type and surgical treatment allocation and outcomes for patients with SAH while adjusting for a wide range of patient and hospital factors. We analyzed the Nationwide Inpatient Sample hospital discharge database using survey procedures to produce weighted estimates representative of the United States population.

PATIENTS

We studied 21047 discharges, representing a weighted estimate of 102595 patients age 18 and above with a discharge diagnosis of SAH between 2003 and 2008.

MEASUREMENTS

Multivariable logistic and generalized linear regression analyses were used to assess for any associations between insurance status and surgery allocation and outcomes.

MAIN RESULTS

Despite the benefits of surgery 66% of SAH patients did not undergo surgical treatment to prevent rebleeding. Mortality was more than twice as likely for patients with no surgical treatment compared to those who received surgery. Medicare patients were significantly less likely to receive surgical treatment.

CONCLUSIONS

Nearly two thirds of patients with SAH don't receive operative care, and Medicare patients were significantly less likely to receive surgical treatment than other patients. Bias against the elderly and those with chronic illness and disability may play a part in these findings. A system of regionalized care for patients presenting with SAH may reduce disparities and improve appropriate allocation to surgical care and deserves prospective study.

THE QUALITY OF TREATMENT EVALUATION IN REGISTRIES FOR ACUTE CEREBRAL CIRCULATION DISORDERS. FOREIGN EXPERIENCE, RUSSIAN PERSPECTIVES

In the review the most prominent foreign registries of stroke are explored, those concern the evaluation of the treatment, and several Russian registries. The importance of treatment evaluation is discussed, and better and worse sides of the evaluating systems are estimated as their possibility to be used it Russia. 

Predictors of 30-day readmission after subarachnoid hemorrhage

BACKGROUND

Readmission within 30 days is increasingly evaluated as a measure of quality of care. There are few data on the rates of readmission after subarachnoid hemorrhage (SAH).

OBJECTIVE

We sought to determine the predictors of 30-day readmission in patients with SAH.

METHODS

We prospectively identified 283 patients with SAH admitted between 2006 and 2012. Readmission was determined by means of an automated query with confirmation in the electronic medical record.

RESULTS

Overall, 21 (8 %) patients were readmitted for infection (n = 8), headache (n = 5), hydrocephalus (n = 4), cardiovascular causes (n = 2), medication-related complications (n = 1), and cerebral ischemia (n = 1). Readmission was associated with longer intensive care unit (ICU) length of stay (LOS) (15.4 [13.4-19.3] vs. 12.2 [8.2-18.5] days, P = 0.02), hospital LOS (22.2 [17.4-23.0] vs. 16.8 [12.0-24.1] days, P = 0.01), and placement of an external ventricular drain (EVD, OR 3.9, 95 % CI 1.3-12.0, P = 0.01). Readmission was not associated with admission neurologic grade, NIH Stroke scale at 14 days, modified Rankin scale at 3 months, history of cardiovascular disease, or radiographic cerebral infarction (P > 0.1).

CONCLUSIONS

Demographics, severity of neurologic injury, radiographic cerebral infarction, and outcomes were not associated with readmission after SAH. Markers of a more complicated hospital course (ICU and hospital LOS, EVD placement) were associated with 30-day readmission. Most readmissions were for infections acquired after discharge. Readmission within 30 days is difficult to predict, and, since the most common reason was infection acquired after discharge, it may be difficult to prevent without an integrated health system and coordinated care.

Impact of transpulmonary thermodilution-based cardiac contractility and extravascular lung water measurements on clinical outcome of patients with Takotsubo cardiomyopathy after subarachnoid hemorrhage: a retrospective observational study

Introduction

Takotsubo cardiomyopathy (TCM) is a life-threatening systemic consequence early after subarachnoid hemorrhage (SAH), but precise hemodynamics and related outcomes have not been studied. The purpose of this study was to investigate TCM-induced cardiac function by transpulmonary thermodilution and its impact on clinical outcome of SAH.

Methods

We retrospectively analyzed 46 consecutive postoperative SAH patients who developed TCM. Patients were divided into two groups of echocardiographic left ventricular ejection fraction (LVEF) <40% (TCM with left ventricular (LV) dysfunction) and LVEF ≥40% (TCM without LV dysfunction). Cardiac function index (CFI) and extravascular lung water index (ELWI) were monitored by transpulmonary thermodilution in parallel with serial measurements of echocardiographic parameters and blood biochemical markers.

Results

Transpulmonary thermodilution-derived CFI was significantly correlated with LVEF (r = 0.82, P < 0.0001). The CFI between days 0 and 7 was significantly lower in patients with LV dysfunction (LVEF <40%) than in patients with LVEF ≥40% (P < 0.05). CFI had a better ability than cardiac output to detect cardiac dysfunction (LVEF <40%) (area under the curve = 0.85 ± 0.02; P < 0.001). A CFI value <4.2 min⁻¹ had a sensitivity of 82% and specificity of 84% for detecting LVEF <40%. CFI <4.2 min⁻¹ was associated with delayed cerebral ischemia (DCI) (odds ratio (OR) = 2.14, 95% confidence interval (CI) = 1.33 to 2.86; P = 0.004) and poor 3-month functional outcome on a modified Rankin Scale of 4 to 6 (OR = 1.87, 95% CI = 1.06 to 3.29; P = 0.02). An extravascular lung water index (ELWI) >14 ml/kg after day 4 increased the risk of poor functional outcome at 3-month follow-up (OR = 2.10, 95% CI = 1.11 to 3.97; P = 0.04).

Conclusions

Prolonged cardiac dysfunction and pulmonary edema increased the risk of DCI and poor 3-month functional outcome in postoperative SAH patients with TCM. Serial measurements of CFI and ELWI by transpulmonary thermodilution may provide an easy bedside method of detecting early changes in cardiopulmonary function to direct proper post-SAH treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0482-4) contains supplementary material, which is available to authorized users.

Imaging and decision-making in neurocritical care

Critically ill neurologic patients are common in the hospital practice of neurology and are often in extreme states requiring accurate and specific information. Imaging, especially using advanced imaging techniques, can provide an important means of garnering this information. This article focuses on the clinical utilization of selective imaging methods that are commonly used in critically ill neurologic patients to render diagnoses, to monitor effects of treatment, or have contributed to a better understanding of pathophysiology in the intensive care unit.

Endovascular and surgical options for ruptured middle cerebral artery aneurysms: review of the literature

Middle cerebral artery (MCA) aneurysms are common entities, and those of the bifurcation are the most frequently encountered sublocation of MCA aneurysm. MCA bifurcation (MBIF) aneurysms commonly present with subarachnoid hemorrhage (SAH), are devastating, and are often lethal. At the present time, the treatment of ruptured MBIF aneurysms entails either endovascular or open microneurosurgical methods to permanently secure the aneurysm(s). The purpose of this report is to review the current available data regarding the relative superiority of endovascular versus open microneurosurgical clipping for the treatment of ruptured middle cerebral artery bifurcation aneurysms.

Nanoparticles and stem cells - has targeted therapy for aneurysms finally arrived?

Until recently, endovascular management of intracranial aneurysms has focused on mechanical and hemodynamic aspects: characterizing aneurysm morphology by angiogram, mechanical obstruction by detachable coils, and flow diversion with endovascular stents. Although now common practice, these interventions only ward off aneurysm rupture. The source of the problem, disease of the vessel wall itself, remains. New imaging technology and treatment modalities, however, are offering great promise to the field. In this review, we outline several new developments in the recent literature and pose potential adaptations toward cerebral aneurysms using them. The incidence, presentation, and contemporary endovascular treatment for aneurysms are first reviewed to lay the groundwork for new adaptations. Nanoparticles, including ultrasmall supraparagmenetic iron oxide particles (USPIOs), are next explored as a novel mechanism of predicting aneurysm wall instability and as an agent themselves for aneurysm occlusion. Cellular transplant grafts, bone marrow-derived stem cells (BM-MSCs), and endothelial progenitor cells (EPCs) are then investigated, with the role of cellular differentiation, chemokine secretion, and integration into the injured vascular wall receiving particular emphasis. Several promising translational papers are next discussed, with review of multiple studies that show benefit in aneurysm treatment and endovascular stenting using these agents as adjuncts. We next adapt these research findings into several potential applications we feel may be promising directions for the aspiring researcher. These new treatments may one day strengthen the arsenal of the endovascular neurosurgeon.

The AGTR1 gene A1166C polymorphism as a risk factor and outcome predictor of primary intracerebral and aneurysmal subarachnoid hemorrhages

Associations between the angiotensin II type 1 receptor (AGTR1) gene A1166C polymorphism and hypertension, aortic abdominal aneurysms (as a risk factor) as well as cardiovascular disorders (as a risk factor and an outcome predictor) have been demonstrated. We aimed to investigate the role of this polymorphism as risk factors and outcome predictors in primary intracerebral hemorrhage (PICH) and aneurysmal subarachnoid hemorrhage (aSAH). We have prospectively recruited 1078 Polish participants to the study: 261 PICH patients, 392 aSAH patients, and 425 unrelated control subjects. The A1166C AGTR1 gene polymorphism was studied using the tetra-primer ARMS-PCR method. Allele and genotype frequencies were compared with other ethnically different populations. The A1166C polymorphism was not associated with the risk of PICH or aSAH. Among the aSAH patients the AA genotype was associated with a good outcome, defined by a Glasgow Outcome Scale of 4 or 5 (p<0.02). The distribution of A1166C genotypes in our cohort did not differ from other white or other populations of European descent. In conclusion, we found an association between the A1166C AGTR1 polymorphism and outcome of aSAH patients, but not with the risk of PICH or aSAH.

Monitoring in Neurointensive Care - The Challenge to Detect Delayed Cerebral Ischemia in High-Grade Aneurysmal SAH

Delayed cerebral ischemia (DCI) is a feared and significant medical complication following aneurysmal subarachnoid hemorrhage (aSAH). It occurs in about 30% of patients surviving the initial hemorrhage, mostly between days 4 and 10 after aSAH. Clinical deterioration attributable to DCI is a diagnosis of exclusion and especially difficult to diagnose in patients who are comatose or sedated. The latter are typically patients with a high grade on the World Federation of Neurosurgical Societies scale (WFNS grade 4-5), who represent approximately 40-70% of the patient population with ruptured aneurysms. In this group of patients, the incidence of DCI is often underestimated and higher when compared to low WFNS grade patients. To overcome difficulties in diagnosing DCI, which is especially relevant in sedated and comatose patients, the article reports the most recent recommendation for definition of DCI and discusses their advantages and problematic issues in neurocritical care practice. Finally, appropriate neuromonitoring techniques and their clinical impact in high-grade SAH patients are summarized.

Perianeurysmal edema as a predictive sign of aneurysmal rupture

Subarachnoid hemorrhage following intracranial aneurysmal rupture is a major cause of morbidity and mortality. Several factors may affect the probability of rupture, such as tobacco and alcohol use; size, shape, and location of the aneurysm; presence of intraluminal thrombus; and even the sex of the patient. However, few data correlate such findings with the timing of aneurysmal rupture. The authors report 2 cases of middle-age women with headache and MRI findings of incidental aneurysms. Magnetic resonance imaging showed evidence of surrounding parenchymal edema, and in one case there was a clear increase in edema during follow-up, suggesting a progressive inflammatory process that culminated with rupture. These findings raise the possibility that bleb formation and an enlargement of a cerebral aneurysm might be associated with an inflammatory reaction of the aneurysm wall resulting in perianeurysmal edema and subsequent aneurysmal rupture. There may be a temporal link between higher degree of edema and higher risk for rupture, including risk for immediate rupture.

Inter-observer variability in diagnosing radiological features of aneurysmal subarachnoid hemorrhage; a preliminary single centre study comparing observers from different specialties and levels of training

Background:

A noncontrast computed tomography (CT) scan remains the initial radiological investigation of choice for a patient with suspected aneurysmal subarachnoid hemorrhage (aSAH). This initial scan may be used to derive key information about the underlying aneurysm which may aid in further management. The interpretation, however, is subject to the skill and experience of the interpreting individual. The authors here evaluate the interpretation of such CT scans by different individuals at different levels of training, and in two different specialties (Radiology and Neurosurgery).

Methods:

Initial nonontrast CT scan of 35 patients with aSAH was evaluated independently by four different observers. The observers selected for the study included two from Radiology and two from Neurosurgery at different levels of training; a resident currently in mid training and a resident who had recently graduated from training of each specialty. Measured variables included interpreter's suspicion of presence of subarachnoid blood, side of the subarachnoid hemorrhage, location of the aneurysm, the aneurysm's proximity to vessel bifurcation, number of aneurysm(s), contour of aneurysm(s), presence of intraventricular hemorrhage (IVH), intracerebral hemorrhage (ICH), infarction, hydrocephalus and midline shift. To determine the inter-observer variability (IOV), weighted kappa values were calculated.

Results:

There was moderate agreement on most of the CT scan findings among all observers. Substantial agreement was found amongst all observers for hydrocephalus, IVH, and ICH. Lowest agreement rates were seen in the location of aneurysm being supra or infra tentorial. There were, however, some noteworthy exceptions. There was substantial to almost perfect agreement between the radiology graduate and radiology resident on most CT findings. The lowest agreement was found between the neurosurgery graduate and the radiology graduate.

Conclusion:

Our study suggests that although agreements were seen in the interpretation of some of the radiological features of aSAH, there is still considerable IOV in the interpretation of most features among physicians belonging to different levels of training and different specialties. Whether these might affect management or outcome is unclear.

Relationship between systolic blood pressures measured in emergency department and outcomes in patients with subarachnoid hemorrhage

Aim

High blood pressure is observed frequently in patients with subarachnoid hemorrhage who present to the emergency department. Although extremely high blood pressure is known to predict poor outcomes in patients with spontaneous intracerebral hemorrhage, the relationship between high blood pressure and outcomes has been studied less frequently in patients with subarachnoid hemorrhage.

Methods

A retrospective study was carried out to evaluate whether high blood pressure observed in the emergency department was predictive of poor outcomes in patients with subarachnoid hemorrhage. Three-hundred and twelve subarachnoid hemorrhage patients who were admitted to our institution were quadrichotomized based on their initial systolic blood pressure: <140 mmHg (n = 60), 140-184 mmHg (n = 144), 185-219 mmHg (n = 64), and ≥220 mmHg (n = 44). Demographics including subarachnoid hemorrhage severity (World Federation of Neurosurgical Societies grade) and outcome variables evaluated with the modified Rankin scale 30 days after admission were compared among the four blood pressure groups. Furthermore, an effort was made to delineate a threshold value of systolic blood pressure predictive of outcomes by receiver operating characteristic curve analysis.

Results

The frequency of grade V subarachnoid hemorrhage in the ≥220 mmHg group (55%) was significantly higher than in the other three blood pressure groups. The frequency of patients scoring 5-6 on the modified Rankin scale in the ≥220 mmHg group (54%) was significantly higher than in the other three blood pressure groups. The cut-off systolic blood pressure value predicting poor outcomes (modified Rankin scale 5-6) determined by receiver operating characteristic curve analysis was 189 mmHg.

Conclusions

The higher proportion of grade V patients may be responsible for the worse outcomes in the group with systolic blood pressure ≥220 mmHg. Initial systolic blood pressure ≥220 mmHg may be a crude indicator of poor outcomes in patients with subarachnoid hemorrhage.

Optimal range of global end-diastolic volume for fluid management after aneurysmal subarachnoid hemorrhage: a multicenter prospective cohort study

OBJECTIVES

Limited evidence supports the use of hemodynamic variables that correlate with delayed cerebral ischemia or pulmonary edema after aneurysmal subarachnoid hemorrhage. The aim of this study was to identify those hemodynamic variables that are associated with delayed cerebral ischemia and pulmonary edema after subarachnoid hemorrhage.

DESIGN

A multicenter prospective cohort study.

SETTING

Nine university hospitals in Japan.

PATIENTS

A total of 180 patients with aneurysmal subarachnoid hemorrhage.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were prospectively monitored using a transpulmonary thermodilution system in the 14 days following subarachnoid hemorrhage. Delayed cerebral ischemia was developed in 35 patients (19.4%) and severe pulmonary edema was developed in 47 patients (26.1%). Using the Cox proportional hazards model, the mean global end-diastolic volume index (normal range, 680-800 mL/m) was the independent factor associated with the occurrence of delayed cerebral ischemia (hazard ratio, 0.74; 95% CI, 0.60-0.93; p = 0.008). Significant differences in global end-diastolic volume index were detected between the delayed cerebral ischemia and non-delayed cerebral ischemia groups (783 ± 25 mL/m vs 870 ± 14 mL/m; p = 0.007). The global end-diastolic volume index threshold that best correlated with delayed cerebral ischemia was less than 822 mL/m, as determined by receiver operating characteristic curves. Analysis of the Cox proportional hazards model indicated that the mean global end-diastolic volume index was the independent factor that associated with the occurrence of pulmonary edema (hazard ratio, 1.31; 95% CI, 1.02-1.71; p = 0.03). Furthermore, a significant positive correlation was identified between global end-diastolic volume index and extravascular lung water (r = 0.46; p < 0.001). The global end-diastolic volume index threshold that best correlated with severe pulmonary edema was greater than 921 mL/m.

CONCLUSIONS

Our findings suggest that global end-diastolic volume index impacts both delayed cerebral ischemia and pulmonary edema after subarachnoid hemorrhage. Maintaining global end-diastolic volume index slightly above normal levels has promise as a fluid management goal during the treatment of subarachnoid hemorrhage.

The harmful effects of subarachnoid hemorrhage on extracerebral organs

Subarachnoid hemorrhage (SAH) is a devastating neurological disorder. Patients with aneurysmal SAH develop secondary complications that are important causes of morbidity and mortality. Aside from secondary neurological injuries, SAH has been associated with nonneurologic medical complications, such as neurocardiogenic injury, neurogenic pulmonary edema, hyperglycemia, and electrolyte imbalance, of which cardiac and pulmonary complications are most common. The related mechanisms include activation of the sympathetic nervous system, release of catecholamines and other hormones, and inflammatory responses. Extracerebral complications are directly related to the severity of SAH-induced brain injury and indicate the clinical outcome in patients. This review provides an overview of the extracerebral complications after SAH. We also aim to describe the manifestations, underlying mechanisms, and the effects of those extracerebral complications on outcome following SAH.

General technical considerations for the endovascular management of cerebral aneurysms

Cerebral aneurysms pose a threat to patients because of their risk of rupture causing subarachnoid hemorrhage, and the goal of treatment is the exclusion of the aneurysm from the circulation to prevent bleeding (in the case of unruptured aneurysms) or rebleeding. This article analyzes the general technical factors associated with the endovascular treatment of cerebral aneurysms. It discusses issues with transarterial access; imaging of aneurysm size, morphology, and regional anatomy to determine the endovascular plan; the techniques for the major endovascular aneurysm devices; and periprocedural management issues to reduce potential treatment-related complications.

Nonaneurysmal perimesencephalic subarachnoid hemorrhage: diagnosis, pathophysiology, clinical characteristics, and long-term outcome

Patients with nonaneurysmal perimesencephalic subarachnoid hemorrhage (NAPSAH) have no discernible source for the bleeding and generally are considered to have a benign condition. Correctly diagnosing these patients is essential because a missed aneurysm can have catastrophic consequences. Those presenting with NAPSAH have a low risk of complications and better outcome than patients presenting with aneurysmal subarachnoid hemorrhage; however, a limited body of literature suggests that not all of these patients are able to return to their premorbid functional status. Clinical screens of cognitive status, such as the mini-mental status examination, suggest good recovery of these patients, although these tests may lack sensitivity for identifying deficits in this patient population. More comprehensive neuropsychologic testing in some studies has identified deficits in a wide range of cognitive domains at long-term follow-up in patients with NAPSAH. Because these patients often do not lose consciousness (and thus do not have substantial transient global ischemia) and they do not undergo a procedure for aneurysm repair, the cognitive sequelae can be explained by the presence of blood in the subarachnoid space. NAPSAH presents an opportunity to understand the effects of subarachnoid blood in a clinical setting.