201
|
Panni P, Riccio L, Cao R, Pedicelli A, Marchese E, Caricato A, Feletti A, Testa M, Zanatta P, Gitti N, Piva S, Mardighian D, Semeraro V, Nardin G, Lozupone E, Paiano G, Picetti E, Montanaro V, Petranca M, Bortolotti C, Scibilia A, Cirillo L, Lanterna AL, Ambrosi A, Mortini P, Beretta L, Falini A. Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry. Neurosurgery 2023; 93:636-645. [PMID: 37010298 DOI: 10.1227/neu.0000000000002467] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/27/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Scarce data are available regarding rebleeding predictors in poor-grade aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVES To investigate predictors and clinical impact of rebleeding in a national multicentric poor-grade aSAH. METHODS Retrospective analysis of prospectively collected data from the multicentric Poor Grade Aneurysmal Subarachnoid Hemorrhage Study Group (POGASH) registry of consecutive patients treated from January 1, 2015, to June 30th, 2021. Grading was defined as pretreatment World Federation of Neurological Surgeons grading scale IV-V. Ultra-early vasospasm (UEV) was defined as luminal narrowing of intracranial arteries not due to intrinsic disease. Rebleeding was defined as clinical deterioration with evidence of increased hemorrhage on subsequent computed tomography scans, fresh blood from the external ventricular drain, or deterioration before neuroradiological evaluation. Outcome was assessed by the modified Rankin Scale. RESULTS Among 443 consecutive World Federation of Neurological Surgeons grades IV-V patients with aSAH treated within a median of 5 (IQR 4-9) hours since onset, rebleeding occurred in 78 (17.6%). UEV (adjusted odds ratio [OR] 6.8, 95% CI 3.2-14.4; P < .001) and presence of dissecting aneurysm (adjusted OR 3.5, 95% CI 1.3-9.3; P = .011) independently predicted rebleeding while history of hypertension (adjusted OR 0.4, 95% CI 0.2-0.8; P = .011) independently reduced its chances. 143 (32.3) patients died during hospitalization. Rebleeding emerged, among others, as an independent predictor of intrahospital mortality (adjusted OR 2.2, 95% CI 1.2-4.1; P = .009). CONCLUSION UEV and presence of dissecting aneurysms are the strongest predictors of aneurysmal rebleeding. Their presence should be carefully evaluated in the acute management of poor-grade aSAH.
Collapse
Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Lucia Riccio
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberta Cao
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Pedicelli
- Institute of Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care Medicine Fondazione Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Alberto Feletti
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mattia Testa
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paolo Zanatta
- Anesthesia and Intensive Care A, Integrated University Hospital, Verona, Italy
| | - Nicola Gitti
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Dikran Mardighian
- Department of Neuroradiology Spedali Civili University Hospital, Brescia, Italy
| | | | - Giordano Nardin
- Department of Critical Care, SS Annunziata Hospital, Taranto, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito-Fazzi Hospital, Lecce, Italy
| | - Giafranco Paiano
- Department of Anaesthesia and Critical Care, Vito-Fazzi Hospital, Lecce, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Vito Montanaro
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Massimo Petranca
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Carlo Bortolotti
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Antonino Scibilia
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Luigi Cirillo
- Department of Neuroradiology, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | | | | | - Pietro Mortini
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Beretta
- Department of Neurocritical Care San Raffaele University Hospital, Milan, Italy
| | - Andrea Falini
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
202
|
Leppert J, Ditz C, Souayah N, Behrens C, Tronnier VM, Küchler J. Limitations of prone positioning in patients with aneurysmal subarachnoid hemorrhage and concomitant respiratory failure. Clin Neurol Neurosurg 2023; 232:107878. [PMID: 37423091 DOI: 10.1016/j.clineuro.2023.107878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Prone positioning (PP) is an established treatment modality for respiratory failure. After aneurysmal subarachnoid hemorrhage (aSAH), PP is rarely performed considering the risk of intracranial hypertension. The aim of this study was to analyze the effects of PP on intracranial pressure (ICP), cerebral perfusion pressure (CPP) and cerebral oxygenation following aSAH. PATIENTS AND METHODS Demographic and clinical data of aSAH patients admitted over a 6-year period and treated with PP due to respiratory insufficiency were retrospectively analyzed. ICP, CPP, brain tissue oxygenation (pBrO2), respiratory parameters and ventilator settings were analyzed before and during PP. RESULTS Thirty patients receiving invasive multimodal neuromonitoring were included. Overall, 97 PP sessions were performed. Mean arterial oxygenation and pBrO2 increased significantly during PP. We found a significant increase in median ICP compared to the baseline level in supine position. No significant changes in CPP were observed. Five PP sessions had to be terminated early due to medically refractory ICP-crisis. The affected patients were younger (p = 0.02) with significantly higher baseline ICP values (p = 0.009). Baseline ICP correlates significantly (p < 0.001) with ICP 1 h (R: 0.57) and 4 h (R: 0.55) after onset of PP. CONCLUSION PP in aSAH patients with respiratory insufficiency is an effective therapeutic option improving arterial and global cerebral oxygenation without compromising CPP. The significant increase in ICP was moderate in most sessions. However, as some patients experience intolerable ICP crises during PP, continuous ICP-Monitoring is considered mandatory. Patients with elevated baseline ICP and reduced intracranial compliance should not be considered for PP.
Collapse
Affiliation(s)
- Jan Leppert
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
| | - Noura Souayah
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Carianne Behrens
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Volker M Tronnier
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| |
Collapse
|
203
|
Capion T, Lilja-Cyron A, Olsen MH, Juhler M, Møller K, Sorteberg A, Rønning PA, Poulsen FR, Wismann J, Ravlo C, Isaksen J, Lindschou J, Gluud C, Mathiesen T. Prompt closure versus gradual weaning of external ventricular drainage for hydrocephalus following aneurysmal subarachnoid haemorrhage: Protocol for the DRAIN randomised clinical trial. Acta Anaesthesiol Scand 2023; 67:1121-1127. [PMID: 37165711 DOI: 10.1111/aas.14263] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening disease caused by rupture of an intracranial aneurysm. A common complication following aSAH is hydrocephalus, for which placement of an external ventricular drain (EVD) is an important first-line treatment. Once the patient is clinically stable, the EVD is either removed or replaced by a ventriculoperitoneal shunt. The optimal strategy for cessation of EVD treatment is, however, unknown. Gradual weaning may increase the risk of EVD-related infection, whereas prompt closure carries a risk of acute hydrocephalus and redundant shunt implantations. We designed a randomised clinical trial comparing the two commonly used strategies for cessation of EVD treatment in patients with aSAH. METHODS DRAIN is an international multi-centre randomised clinical trial with a parallel group design comparing gradual weaning versus prompt closure of EVD treatment in patients with aSAH. Participants are randomised to either gradual weaning which comprises a multi-step increase of resistance over days, or prompt closure of the EVD. The primary outcome is a composite outcome of VP-shunt implantation, all-cause mortality, or ventriculostomy-related infection. Secondary outcomes are serious adverse events excluding mortality, functional outcome (modified Rankin scale), health-related quality of life (EQ-5D) and Fatigue Severity Scale (FSS). Outcome assessment will be performed 6 months after ictus. Based on the sample size calculation (event proportion 80% in the gradual weaning group, relative risk reduction 20%, type I error 5%, power 80%), 122 patients are needed in each intervention group. Outcome assessment for the primary outcome, statistical analyses and conclusion drawing will be blinded. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03948256.
Collapse
Affiliation(s)
- Tenna Capion
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Alexander Lilja-Cyron
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- BRIDGE (Brain Research-Inter Disciplinary Guided Excellence), University of Southern Denmark, Odense, Denmark
| | - Joakim Wismann
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- BRIDGE (Brain Research-Inter Disciplinary Guided Excellence), University of Southern Denmark, Odense, Denmark
| | - Celina Ravlo
- Department of Neurosurgery, Ophthalmology and Otorhinolaryngology, Division of Clinical Neurosciences, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Jørgen Isaksen
- Department of Neurosurgery, Ophthalmology and Otorhinolaryngology, Division of Clinical Neurosciences, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Tiit Mathiesen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
204
|
Vergouwen MDI, Germans MR, Post R, Tjerkstra MA, Coert BA, Rinkel GJE, Peter Vandertop W, Verbaan D. Aneurysm treatment within 6 h versus 6-24 h after rupture in patients with subarachnoid hemorrhage. Eur Stroke J 2023; 8:802-807. [PMID: 37641555 PMCID: PMC10472949 DOI: 10.1177/23969873231173273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/14/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The risk of rebleeding after aneurysmal subarachnoid hemorrhage (aSAH) is the highest during the initial hours after rupture. Emergency aneurysm treatment may decrease this risk, but is a logistic challenge and economic burden. We aimed to investigate whether aneurysm treatment <6 h after rupture is associated with a decreased risk of poor functional outcome compared to aneurysm treatment 6-24 h after rupture. METHODS We used data of patients included in the ULTRA trial (NCT02684812). All patients in ULTRA were admitted within 24 h after aneurysm rupture. For the current study, we excluded patients in whom the aneurysm was not treated <24 h after rupture. We calculated crude and adjusted risk ratios (aRR) with 95% confidence intervals using Poisson regression analyses for poor functional outcome (death or dependency, assessed by the modified Rankin Scale) after aneurysm treatment <6 h versus 6-24 h after rupture. Adjustments were made for age, sex, clinical condition on admission (WFNS scale), amount of extravasated blood (Fisher score), aneurysm location, tranexamic acid treatment, and aneurysm treatment modality. RESULTS We included 497 patients. Poor outcome occurred in 63/110 (57%) patients treated within 6 h compared to 145/387 (37%) patients treated 6-24 h after rupture (crude RR: 1.53, 95% CI: 1.24-1.88; adjusted RR: 1.36, 95% CI: 1.11-1.66). CONCLUSION Aneurysm treatment <6 h is not associated with better functional outcome than aneurysm treatment 6-24 h after rupture. Our results do not support a strategy aiming to treat every patient with a ruptured aneurysm <6 h after rupture.
Collapse
Affiliation(s)
- Mervyn DI Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - René Post
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Gabriel JE Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - William Peter Vandertop
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| |
Collapse
|
205
|
Topcu A, Ozkul A, Yilmaz A, Yi HJ, Shin DS, Kim B. The impact of collateral status on cerebral vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2023; 25:288-296. [PMID: 37232069 PMCID: PMC10555627 DOI: 10.7461/jcen.2023.e2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/23/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE Cerebral collateral circulation may affect subarachnoid hemorrhage (SAH) induced cerebral vasospasm and delayed cerebral ischemia. In this study our aim was to investigate the relationship between collateral status, vasospasm and delayed cerebral ischemia (DCI) in both aneurysmal and nonaneurysmal SAH. METHODS Patients diagnosed as SAH with and without aneurysm were included and their data investigated retrospectively. After the patients diagnosed as SAH according to cerebral computed tomography (CT)/magnetic resonance imaging (MRI), they underwent cerebral angiography to check for cerebral aneurysm. The diagnosis of DCI was made according to the neurological examination and control CT/MRI. All the patients had their control cerebral angiography on days 7 to 10 in order to assess vasospasm and also collateral circulation. The American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) Collateral Flow Grading System was modified to measure collateral circulation. RESULTS A total of 59 patients data were analyzed. Patients with aneurysmal SAH had higher Fisher scores and DCI was more common. Although there was no statistically significant difference between the patients with and without DCI in terms of demographics and mortality, patients with DCI had worse collateral circulation and more severe vasospasm. These patients had higher Fisher scores and more cerebral aneurysm overall. CONCLUSIONS According to our data, patients with higher Fisher scores, more severe vasospasm, and poor cerebral collateral circulation may experience DCI more frequently. Additionally aneurysmal SAH had higher Fisher scores and DCI was seen more common. To improve the clinical results for SAH patients, we believe that physicians should be aware of the DCI risk factors.
Collapse
Affiliation(s)
- Abdullah Topcu
- Department of Neurosurgery, Adnan Menderes University Faculty of Medicine, Aydın, Tükiye
| | - Ayca Ozkul
- Department of Neurology, Adnan Menderes University Faculty of Medicine, Aydın, Tükiye
| | - Ali Yilmaz
- Department of Neurosurgery, Adnan Menderes University Faculty of Medicine, Aydın, Tükiye
| | - Ho Jun Yi
- Department of Neurosurgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Dong Seong Shin
- Department of Neurosurgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - BumTae Kim
- Department of Neurosurgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| |
Collapse
|
206
|
Zachrison KS, Goldstein JN, Jauch E, Radecki RP, Madsen TE, Adeoye O, Oostema JA, Feeser VR, Ganti L, Lo BM, Meurer W, Corral M, Rothenberg C, Chaturvedi A, Goyal P, Venkatesh AK. Clinical Performance Measures for Emergency Department Care for Adults With Intracranial Hemorrhage. Ann Emerg Med 2023; 82:258-269. [PMID: 37074253 DOI: 10.1016/j.annemergmed.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 04/20/2023]
Abstract
Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage, emergency departments lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative. To develop the measure set, we convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure: internal quality improvement, benchmarking, or accountability, and examined data from Emergency Quality Network Stroke Initiative-participating EDs to consider the validity and feasibility of proposed measures for quality measurement and improvement applications. The initially conceived set included 14 measure concepts, of which 7 were selected for inclusion in the measure set after a review of data and further deliberation. Proposed measures include 2 for quality improvement, benchmarking, and accountability (Last 2 Recorded Systolic Blood Pressure Measurements Under 150 and Platelet Avoidance), 3 for quality improvement and benchmarking (Proportion of Patients on Oral Anticoagulants Receiving Hemostatic Medications, Median ED Length of Stay for admitted patients, and Median Length of Stay for transferred patients), and 2 for quality improvement only (Severity Assessment in the ED and Computed Tomography Angiography Performance). The proposed measure set warrants further development and validation to support broader implementation and advance national health care quality goals. Ultimately, applying these measures may help identify opportunities for improvement and focus quality improvement resources on evidence-based targets.
Collapse
Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Ryan P Radecki
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University School of Medicine in St Louis, St Louis, MO
| | - John A Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, East Lansing, MI
| | - V Ramana Feeser
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA
| | - Latha Ganti
- Department of Emergency Medicine, University of Central Florida College of Medicine, Orlando, FL
| | - Bruce M Lo
- Department of Emergency Medicine, Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, VA
| | - William Meurer
- Departments of Emergency Medicine and Neurology, University of Michigan Medical School, Ann Arbor, MI
| | | | - Craig Rothenberg
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | | | - Pawan Goyal
- American College of Emergency Physicians, Irving, TX
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| |
Collapse
|
207
|
Wang K, Li R, Chen X, Zhao Y, Hao Q. Platelet-to-white blood cell ratio: A feasible predictor for unfavorable functional outcome in patients with aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2023; 115:108-113. [PMID: 37544205 DOI: 10.1016/j.jocn.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 08/08/2023]
Abstract
This study aimed to identify the association between the platelet-to-white blood cell ratio (PWR) and outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). Data for patients diagnosed with aSAH and admitted from January 2015 to December 2020 were retrospectively analyzed. Multivariate logistic regression analysis was performed to identify factors that correlated with unfavorable outcomes at 3 months. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off value for the PWR to discriminate favorable and unfavorable outcomes at 3 months. The patients were then divided into two groups based on this cut-off value. To reduce selection bias, propensity score matching (PSM) was performed to balance the baseline characteristics. In total, 800 patients were enrolled in this study. The multivariate logistic regression analysis showed that the PWR (odds ratio, 1.05; 95% confidence interval, 1.00-1.09; p = 0.034) at admission was independently associated with unfavorable 3-month outcomes. ROC curve analysis identified 15.69 as the best cut-off PWR value for predicting clinical outcomes. After PSM, patients with a PWR < 15.69 exhibited a higher incidence of postoperative pneumonia (POP) (37.2% vs. 25.6%, p = 0.011) and unfavorable 3-month outcomes (19.3% vs. 12.1%, p = 0.043). These findings suggest that patients with aSAH showing a PWR < 15.69 at admission have a higher probability of developing POP, which may be the main factor causing unfavorable outcomes at 3 months.
Collapse
Affiliation(s)
- Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100070, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100070, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100070, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China.
| |
Collapse
|
208
|
Sorrentino ZA, Desai A, Eisinger RS, Maciel CB, Busl KM, Lucke-Wold B. Evaluating analgesic medications utilized in the treatment of aneurysmal subarachnoid hemorrhage and association with delayed cerebral ischemia. J Clin Neurosci 2023; 115:157-162. [PMID: 37579712 DOI: 10.1016/j.jocn.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/16/2023] [Accepted: 07/26/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Spontaneous aneurysmal subarachnoid hemorrhage (aSAH) recovery may be hampered by delayed cerebral ischemia (DCI). Herein, we sought to identify whether frequently administered medications in the intensive care unit (ICU) are associated with DCI. METHODS In this retrospective study, patients admitted to a tertiary care center neuro-ICU between 2012 and 2019 with aSAH who could verbalize pain intensity scores were included. Medication dosages and clinical characteristics were abstracted from the medical record. Both paired and unpaired analyses were utilized to measure individual DCI risk for a given patient in relation to drug dosages. RESULTS 119 patients were included; average age was 61.7 ± 15.2 (SD) years, 89 (74.7%) were female, and 32 (26.9%) experienced DCI during admission. Patients with DCI had longer length of stay (19.3 ± 7.4 vs 12.7 ± 5.3 days, p < 0.0001). The combination medication of acetaminophen 325 mg/butalbital 50 mg/caffeine 40 mg (A/B/C) was associated with decreased DCI on paired (2.3 ± 2.0 vs 3.1 ± 1.9 tabs, p = 0.034) and unpaired analysis (1.84 ± 2.4 vs 2.6 ± 2.4 tabs, p < 0.001). No associations were found between DCI and opioids, dexamethasone, levetiracetam, or acetaminophen. Max and mean daily headache pain was not associated with DCI occurrence. CONCLUSION We identified an association between a commonly administered analgesic and DCI. A/B/C is associated with decreased DCI in this study, while other medications are not associated with DCI risk.
Collapse
Affiliation(s)
- Zachary A Sorrentino
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Ansh Desai
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Carolina B Maciel
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurology, Yale University, New Haven, CT, USA; Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Katharina M Busl
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, FL, USA
| | - Brandon Lucke-Wold
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA.
| |
Collapse
|
209
|
Wan X, Wu X, Kang J, Fang L, Tang Y. Prognostic model for aneurysmal subarachnoid hemorrhage patients requiring mechanical ventilation. Ann Clin Transl Neurol 2023; 10:1569-1577. [PMID: 37424159 PMCID: PMC10502627 DOI: 10.1002/acn3.51846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/04/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of death and disability worldwide and imposes serious burdens on society and individuals. However, predicting the long-term outcomes in aSAH patients requiring mechanical ventilation remains challenging. We sought to establish a model utilizing the Least Absolute Shrinkage and Selection Operator (LASSO)-penalized Cox regression to estimate the prognosis of aSAH patients requiring mechanical ventilation, based on regularly utilized and easily accessible clinical variables. METHODS Data were retrieved from the Dryad Digital Repository. Potentially relevant features were selected using LASSO regression analysis. Multiple Cox proportional hazards analyses were performed to develop a model using the training set. Receiver operating characteristics and calibration curves were used to assess its predictive accuracy and discriminative power. Kaplan-Meier and decision curve analyses (DCA) were used to evaluate the clinical utility of the model. RESULTS Independent prognostic factors, including the Simplified Acute Physiology Score 2, early brain injury, rebleeding, and length of intensive care unit stay, were identified and included in the nomogram. In the training set, the area under the curve values for 1-, 2-, and 4-year survival predictions were 0.82, 0.81, and 0.80, respectively. In the validation set, the nomogram exhibited excellent discrimination ability and good calibration. Moreover, DCA demonstrated that the nomogram was clinically beneficial. Finally, a web-based nomogram was constructed (https://rehablitation.shinyapps.io/aSAH). INTERPRETATION Our model is a useful tool for accurately predicting long-term outcomes in patients with aSAH who require mechanical ventilation and can assist in making individualized interventions by providing valuable information.
Collapse
Affiliation(s)
- Xichen Wan
- Department of NeurosurgeryFirst Affiliated Hospital of Nanchang UniversityNanchang330006People's Republic of China
| | - Xiao Wu
- Department of NeurosurgeryFirst Affiliated Hospital of Nanchang UniversityNanchang330006People's Republic of China
| | - Junwei Kang
- Department of Rehabilitation MedicineFirst Affiliated Hospital of Nanchang UniversityNanchang330006People's Republic of China
| | - Longjun Fang
- Department of Rehabilitation MedicineFirst Affiliated Hospital of Nanchang UniversityNanchang330006People's Republic of China
| | - Yunliang Tang
- Department of Rehabilitation MedicineFirst Affiliated Hospital of Nanchang UniversityNanchang330006People's Republic of China
| |
Collapse
|
210
|
Salem MM, Khalife J, Desai S, Sharashidze V, Badger C, Kuhn AL, Monteiro A, Salahuddin H, Siddiqui AH, Singh J, Levy EI, Lang M, Grandhi R, Thomas AJ, Lin LM, Tanweer O, Burkhardt JK, Puri AS, Gross BA, Nossek E, Hassan AE, Shaikh HA, Jankowitz BT. COManeci MechANical Dilation for vasospasm (COMMAND): multicenter experience. J Neurointerv Surg 2023; 15:864-870. [PMID: 36002289 DOI: 10.1136/jnis-2022-019272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND We report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm. METHODS Consecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020-2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up. RESULTS A total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3-4) to post-treatment (0-2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0-2) was noted in 51.5% of patients (median follow-up 6 months). CONCLUSIONS The Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted.
Collapse
Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Sohum Desai
- Department of Neuroscience, Valley Baptist Medical Center, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas, USA
| | - Vera Sharashidze
- Department of Neurosurgery, New York University School of Medicine, New York, New York, USA
| | - Clint Badger
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Anna L Kuhn
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Andre Monteiro
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Hisham Salahuddin
- Department of Neurology, Antelope Valley Medical Center, Lancaster, California, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Jasmeet Singh
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Michael Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Li-Mei Lin
- Carondelet Neurological Institute, Carondelet Health Network, Tucson, Arizona, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Erez Nossek
- Department of Neurosurgery, New York University School of Medicine, New York, New York, USA
| | - Ameer E Hassan
- Department of Neuroscience, Valley Baptist Medical Center, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas, USA
| | - Hamza A Shaikh
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
211
|
Wang D, Ma L, Li Z, Ye G, Chen M. Serum Sestrin2 Emerges as a Prognostic Biomarker of Human Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Cohort Single-Center Study. Int J Gen Med 2023; 16:3869-3887. [PMID: 37662499 PMCID: PMC10473418 DOI: 10.2147/ijgm.s428011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/23/2023] [Indexed: 09/05/2023] Open
Abstract
Background Sestrin2 functions as a neuroprotective factor. Herein, serum sestrin2 was investigated with respect to its associations with severity, delayed cerebral ischemia (DCI) and prognosis of aneurysmal subarachnoid hemorrhage (aSAH). Methods In this prospective, observational, cohort, single-center study, serum sestrin2 levels were measured at entry into the study in 45 healthy controls and at admission in 135 aSAH patients. Also, they were gauged in other time points (namely, at days 1, 2, 3, 5 and 7) among 45 patients. Unfavorable prognosis was defined as extended Glasgow Outcome Scale (GOSE) scores of 1-4 at six months after aSAH. Results Serum sestrin2 levels were immediately raised at admission in patients, increased thereafter, peaked at day 2, declined afterwards till day 7, and were significantly higher than those in controls (all P<0.001). Serum sestrin2 levels had independent correlation with Hunt-Hess scores (beta, 1.715; 95% confidence interval (CI), 0.595-2.835; P=0.003) and modified Fisher scores (beta, 2.505; 95% CI, 1.102-3.907; P=0.001). Alternatively, serum sestrin2 levels, which were independently correlated with 6-month GOSE scores (beta, -0.050; 95% CI, -0.099-0.001; P=0.044), were independently associated with DCI (odds ratio, 1.079; 95% CI, 1.008-1.156; P=0.029) and unfavorable prognosis (odds ratio, 1.093; 95% CI, 1.020-1.172; P=0.012). DCI and prognosis prediction models, which were composed of serum sestrin2, Hunt-Hess scores and modified Fisher scores, were comparatively stable and clinically beneficial under calibration curve and decision curve. Prognosis prediction model showed significantly higher area under receiver operating characteristic curve than serum sestrin2, Hunt-Hess scores and modified Fisher scores alone (all P<0.05). Conclusion A significant enhancement of serum sestrin2 levels after aSAH is independently related to severity, DCI and poor prognosis following aSAH. The models incorporating serum sestrin2 perform well in predicting the DCI and prognosis of aSAH patients. Presumably, determination of serum sestrin2 may be of clinical significance in aSAH.
Collapse
Affiliation(s)
- Dongfeng Wang
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, 315100, People’s Republic of China
| | - Lei Ma
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, 315100, People’s Republic of China
| | - Zhenqiang Li
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, 315100, People’s Republic of China
| | - Gengfan Ye
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, 315100, People’s Republic of China
| | - Maosong Chen
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, 315100, People’s Republic of China
| |
Collapse
|
212
|
Burzyńska M, Uryga A, Woźniak J, Załuski R, Robba C, Goździk W. The Role of Early Serum Biomarkers and Clinical Rating Scales in the Prediction of Delayed Cerebral Ischaemia and Short-Term Outcome after Aneurysmal Subarachnoid Haemorrhage: Single Centre Experience. J Clin Med 2023; 12:5614. [PMID: 37685681 PMCID: PMC10488375 DOI: 10.3390/jcm12175614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Considering the variety of complications that arise after aneurysmal subarachnoid haemorrhage (aSAH) and the complex pathomechanism of delayed cerebral ischaemia (DCI), the task of predicting the outcome assumes a profound complexity. Therefore, there is a need to develop early predictive and decision-making models. This study explores the effect of serum biomarkers and clinical scales on patients' outcomes and their interrelationship with DCI and systemic complications in aSAH. This was a retrospective analysis including aSAH patients admitted to the Wroclaw University Hospital (Wrocław, Poland) from 2011 to 2020. A good outcome was defined as a modified Rankin Scale (mRS) score of 0-2. The prediction of the development of DCI and poor outcome was conducted using logistic regression as a standard model (SM) and random forest as a machine learning method (ML). A cohort of 174 aSAH patients were included in the analysis. DCI was diagnosed in 79 (45%) patients. Significant differences between patients with poor vs. good outcome were determined from their levels of albumin (31 ± 7 vs. 35 ± 5 (g/L); p < 0.001), D-dimer (3.0 ± 4.5 vs. 1.5 ± 2.8 (ng/mL); p < 0.001), procalcitonin (0.2 ± 0.4 vs. 0.1 ± 0.1 (ng/mL); p < 0.001), and glucose (169 ± 69 vs. 137 ± 48 (nmol/L); p < 0.001). SM for DCI prediction included the Apache II scale (odds ratio [OD] 1.05; 95% confidence interval [CI] 1.00-1.09) and albumin level (OD 0.88; CI 0.82-0.95). ML demonstrated that low albumin level, high Apache II scale, increased D-dimer and procalcitonin levels had the highest predictive values for DCI. The integration of clinical parameters and scales with a panel of biomarkers may effectively facilitate the stratification of aSAH patients, identifying those at high risk of secondary complications and poor outcome.
Collapse
Affiliation(s)
- Małgorzata Burzyńska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, 50-370 Wroclaw, Poland
| | - Jowita Woźniak
- Department of Neurosurgery, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.W.); (R.Z.)
| | - Rafał Załuski
- Department of Neurosurgery, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.W.); (R.Z.)
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16145 Genoa, Italy
| | - Waldemar Goździk
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
| |
Collapse
|
213
|
Hedges A, Findlay MC, Davis GE, Wolfe BM, Hawryluk GWJ, Menacho ST, Ansari S. Levetiracetam dosing for seizure prophylaxis in neurocritical care patients. Brain Inj 2023; 37:1167-1172. [PMID: 36856437 DOI: 10.1080/02699052.2023.2184495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/21/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND/OBJECTIVE Levetiracetam is used for seizure prophylaxis in patients presenting with subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI). We aim to characterize the optimal levetiracetam dosage for seizure prophylaxis. METHODS This retrospective cohort study included adult patients at an academic tertiary hospital presenting with SAH or TBI who received levetiracetam at a total daily dose (TDD) equivalent to or greater than 1000 mg. The primary outcome was combined seizure incidence, including clinical and subclinical seizures. RESULTS We identified 139 patients (49.6% male, mean age 53 years) for inclusion. For patients receiving a 1000-mg TDD, the administration was 500 mg twice daily. For patients receiving >1000-mg TDD, 77/78 patients received 1000 mg twice daily and one patient received 750 mg twice daily. Patients receiving 1000-mg TDD had a higher seizure incidence than those receiving >1000-mg TDD (p = 0.01), despite no difference in examined confounders, including history of alcoholism (p = 0.49), benzodiazepine use (p = 0.28), or propofol use (p = 0.17). No difference in adverse effects was observed (anemia, p = 0.44; leukopenia, p = 0.60; thrombocytopenia, p = 0.86). CONCLUSIONS Patients may experience a reduced incidence of clinical and electroencephalographic seizures with levetiracetam dosing >1000-mg TDD.
Collapse
Affiliation(s)
- Ashley Hedges
- Department of Pharmacy Services, University of Utah, Salt Lake City, Utah, USA
| | | | - Gary E Davis
- Department of Pharmacy Services, University of Utah, Salt Lake City, Utah, USA
| | - Brianne M Wolfe
- Department of Pharmacy Services, University of Utah, Salt Lake City, Utah, USA
| | | | - Sarah T Menacho
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Safdar Ansari
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
214
|
Athiraman U, Norris AJ, Jayaraman K, Lele AV, Kentner R, Singh PM, Higo OM, Zipfel GJ, Dhar R. Intraoperative Blood Pressure and Carbon Dioxide Values during Aneurysmal Repair and the Outcomes after Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2023; 12:5488. [PMID: 37685555 PMCID: PMC10488211 DOI: 10.3390/jcm12175488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
Cerebral autoregulation impairment is a critical aspect of subarachnoid hemorrhage (SAH)-induced secondary brain injury and is also shown to be an independent predictor of delayed cerebral ischemia (DCI) and poor neurologic outcomes. Interestingly, intraoperative hemodynamic and ventilatory parameters were shown to influence patient outcomes after SAH. The aim of the current study was to evaluate the association of intraoperative hypotension and hypocapnia with the occurrence of angiographic vasospasm, DCI, and neurologic outcomes at discharge. Intraoperative data were collected for 390 patients with aneurysmal SAH who underwent general anesthesia for aneurysm clipping or coiling between January 2010 and May 2018. We measured the mean intraoperative blood pressure and end-tidal carbon dioxide (ETCO2), as well as the area under the curve (AUC) for the burden of hypotension: SBP below 100 or MBP below 65 and hypocapnia (ETCO2 < 30), during the intraoperative period. The outcome measures were angiographic vasospasm, DCI, and the neurologic outcomes at discharge as measured by the modified Rankin scale score (an mRS of 0-2 is a good outcome, and 3-6 is a poor outcome). Univariate and logistic regression analyses were performed to evaluate whether blood pressure (BP) and ETCO2 variables were independently associated with outcome measures. Out of 390 patients, 132 (34%) developed moderate-to-severe vasospasm, 114 (29%) developed DCI, and 46% (169) had good neurologic outcomes at discharge. None of the measured intraoperative BP and ETCO2 variables were associated with angiographic vasospasm, DCI, or poor neurologic outcomes. Our study did not identify an independent association between the degree of intraoperative hypotension or hypocapnia in relation to angiographic vasospasm, DCI, or the neurologic outcomes at discharge in SAH patients.
Collapse
Affiliation(s)
| | - Aaron J. Norris
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Keshav Jayaraman
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Abhijit V. Lele
- Department of Anesthesiology, University of Washington, Seattle, WA 98122, USA
| | - Rainer Kentner
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | | | - Omokhaye M. Higo
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Gregory J. Zipfel
- Departments of Neurological Surgery and Neurology, Washington University, St. Louis, MO 63110, USA
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis, MO 63110, USA
| |
Collapse
|
215
|
Toft-Bertelsen TL, Andreassen SN, Rostgaard N, Olsen MH, Norager NH, Capion T, Juhler M, MacAulay N. Distinct Cerebrospinal Fluid Lipid Signature in Patients with Subarachnoid Hemorrhage-Induced Hydrocephalus. Biomedicines 2023; 11:2360. [PMID: 37760800 PMCID: PMC10525923 DOI: 10.3390/biomedicines11092360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with subarachnoid hemorrhage (SAH) may develop posthemorrhagic hydrocephalus (PHH), which is treated with surgical cerebrospinal fluid (CSF) diversion. This diversion is associated with risk of infection and shunt failure. Biomarkers for PHH etiology, CSF dynamics disturbances, and potentially subsequent shunt dependency are therefore in demand. With the recent demonstration of lipid-mediated CSF hypersecretion contributing to PHH, exploration of the CSF lipid signature in relation to brain pathology is of interest. Despite being a relatively new addition to the omic's landscape, lipidomics are increasingly recognized as a tool for biomarker identification, as they provide a comprehensive overview of lipid profiles in biological systems. We here employ an untargeted mass spectroscopy-based platform and reveal the complete lipid profile of cisternal CSF from healthy control subjects and demonstrate its bimodal fluctuation with age. Various classes of lipids, in addition to select individual lipids, were elevated in the ventricular CSF obtained from patients with SAH during placement of an external ventricular drain. The lipidomic signature of the CSF in the patients with SAH suggests dysregulation of the lipids in the CSF in this patient group. Our data thereby reveal possible biomarkers present in a brain pathology with a hemorrhagic event, some of which could be potential future biomarkers for hypersecretion contributing to ventriculomegaly and thus pharmacological targets for pathologies involving disturbed CSF dynamics.
Collapse
Affiliation(s)
| | - Søren Norge Andreassen
- Department of Neuroscience, University of Copenhagen, 2200 Copenhagen, Denmark; (T.L.T.-B.)
| | - Nina Rostgaard
- Department of Neurosurgery, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
| | - Nicolas H. Norager
- Department of Neurosurgery, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
| | - Tenna Capion
- Department of Neurosurgery, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Nanna MacAulay
- Department of Neuroscience, University of Copenhagen, 2200 Copenhagen, Denmark; (T.L.T.-B.)
| |
Collapse
|
216
|
Nguyen TA, Mai TD, Vu LD, Dao CX, Ngo HM, Hoang HB, Tran TA, Pham TQ, Pham DT, Nguyen MH, Nguyen LQ, Dao PV, Nguyen DN, Vuong HTT, Vu HD, Nguyen DD, Vu TD, Nguyen DT, Do ALN, Nguyen CD, Do SN, Nguyen HT, Nguyen CV, Nguyen AD, Luong CQ. Validation of the accuracy of the modified World Federation of Neurosurgical Societies subarachnoid hemorrhage grading scale for predicting the outcomes of patients with aneurysmal subarachnoid hemorrhage. PLoS One 2023; 18:e0289267. [PMID: 37607172 PMCID: PMC10443875 DOI: 10.1371/journal.pone.0289267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 07/16/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Evaluating the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) who may be at risk of poor outcomes using grading systems is one way to make a better decision on treatment for these patients. This study aimed to compare the accuracy of the modified World Federation of Neurosurgical Societies (WFNS), WFNS, and Hunt and Hess (H&H) Grading Scales in predicting the outcomes of patients with aSAH. METHODS From August 2019 to June 2021, we conducted a multicenter prospective cohort study on adult patients with aSAH in three central hospitals in Hanoi, Vietnam. The primary outcome was the 90-day poor outcome, measured by a score of 4 (moderately severe disability) to 6 (death) on the modified Rankin Scale (mRS). We calculated the areas under the receiver operator characteristic (ROC) curve (AUROCs) to determine how well the grading scales could predict patient prognosis upon admission. We also used ROC curve analysis to find the best cut-off value for each scale. We compared AUROCs using Z-statistics and compared 90-day mean mRS scores among intergrades using the pairwise multiple-comparison test. Finally, we used logistic regression to identify factors associated with the 90-day poor outcome. RESULTS Of 415 patients, 32% had a 90-day poor outcome. The modified WFNS (AUROC: 0.839 [95% confidence interval, CI: 0.795-0.883]; cut-off value≥2.50; PAUROC<0.001), WFNS (AUROC: 0.837 [95% CI: 0.793-0.881]; cut-off value≥3.5; PAUROC<0.001), and H&H scales (AUROC: 0.836 [95% CI: 0.791-0.881]; cut-off value≥3.5; PAUROC<0.001) were all good at predicting patient prognosis on day 90th after ictus. However, there were no significant differences between the AUROCs of these scales. Only grades IV and V of the modified WFNS (3.75 [standard deviation, SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), WFNS (3.75 [SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), and H&H scales (2.96 [SD: 2.60] vs 4.97 [SD: 1.87], p<0.001, respectively) showed a significant difference in the 90-day mean mRS scores. In multivariable models, with the same set of confounding variables, the modified WFNS grade of III to V (adjusted odds ratio, AOR: 9.090; 95% CI: 3.494-23.648; P<0.001) was more strongly associated with the increased risk of the 90-day poor outcome compared to the WFNS grade of IV to V (AOR: 6.383; 95% CI: 2.661-15.310; P<0.001) or the H&H grade of IV to V (AOR: 6.146; 95% CI: 2.584-14.620; P<0.001). CONCLUSIONS In this study, the modified WFNS, WFNS, and H&H scales all had good discriminatory abilities for the prognosis of patients with aSAH. Because of the better effect size in predicting poor outcomes, the modified WFNS scale seems preferable to the WFNS and H&H scales.
Collapse
Affiliation(s)
- Tuan Anh Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Ton Duy Mai
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Stroke Center, Bach Mai Hospital, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Luu Dang Vu
- Radiology Centre, Bach Mai Hospital, Hanoi, Vietnam
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Co Xuan Dao
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Hung Manh Ngo
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Department of Neurosurgery II, Neurosurgery Center, Vietnam-Germany Friendship Hospital, Hanoi, Vietnam
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
| | - Hai Bui Hoang
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Emergency and Critical Care Department, Hanoi Medical University Hospital, Hanoi Medical University, Hanoi, Vietnam
| | - Tuan Anh Tran
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Radiology Centre, Bach Mai Hospital, Hanoi, Vietnam
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Trang Quynh Pham
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
- Department of Neurosurgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Dung Thi Pham
- Department of Nutrition and Food Safety, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - My Ha Nguyen
- Department of Health Organization and Management, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Linh Quoc Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Phuong Viet Dao
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Stroke Center, Bach Mai Hospital, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | | | - Hien Thi Thu Vuong
- Emergency Department, Vietnam-Czechoslovakia Friendship Hospital, Hai Phong, Vietnam
| | - Hung Dinh Vu
- Emergency and Critical Care Department, Hanoi Medical University Hospital, Hanoi Medical University, Hanoi, Vietnam
| | - Dong Duc Nguyen
- Department of Neurosurgery II, Neurosurgery Center, Vietnam-Germany Friendship Hospital, Hanoi, Vietnam
| | - Thanh Dang Vu
- Emergency Department, Agriculture General Hospital, Hanoi, Vietnam
| | | | - Anh Le Ngoc Do
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Cuong Duy Nguyen
- Department of Emergency and Critical Care Medicine, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Son Ngoc Do
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Hao The Nguyen
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
- Department of Neurosurgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Chi Van Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Anh Dat Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Chinh Quoc Luong
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| |
Collapse
|
217
|
Kataria K, Panda NB, Luthra A, Mahajan S, Bhagat H, Chauhan R, Soni S, Jangra K, Kaloria N, Paul S, Bloria S, Gupta S, Chhabra R. Assessment of impaired cerebral autoregulation and its correlation with neurological outcome in aneurysmal subarachnoid hemorrhage: A prospective and observational study. Surg Neurol Int 2023; 14:290. [PMID: 37680917 PMCID: PMC10481860 DOI: 10.25259/sni_25_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 07/11/2023] [Indexed: 09/09/2023] Open
Abstract
Background Cerebral autoregulation (CA) is crucial for the maintenance of cerebral homeostasis. It can be assessed by measuring transient hyperemic response ratio (THRR) using transcranial Doppler (TCD). We aimed at assessing the incidence of impaired CA (ICA) and its correlation with the neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods One hundred consecutive patients with aSAH scheduled for aneurysmal clipping were enrolled in this prospective and observational study. Preoperative and consecutive 5-day postoperative THRR measurements were taken. Primary objective of the study was to detect the incidence of ICA and its correlation with vasospasm (VS) postclipping, and neurological outcome at discharge and 1, 3, and 12 months was secondary objectives. Results ICA (THRR < 1.09) was observed in 69 patients preoperatively, 74 patients on the 1st and 2nd postoperative day, 76 patients on 3rd postoperative day, and 78 patients on 4th and 5th postoperative day. Significant VS was seen in 13.4% and 61.5% of patients with intact THRR and deranged THRR, respectively (P < 0.000). Out of 78 patients who had ICA, 42 patients (53.8%) at discharge, 60 patients (76.9%) at 1 month, 54 patients (69.2%) at 3 month, and 55 patients (70.5%) at 12 months had unfavorable neurological outcome significantly more than those with preserved CA. Conclusion Incidence of ICA assessed in aSAH patients varies from 69% to 78% in the perioperative period. The deranged CA was associated with significantly poor neurological outcome. Therefore, CA assessment using TCD-based THRR provides a simple, noninvasive bedside approach for predicting neurological outcome in aSAH.
Collapse
Affiliation(s)
- Ketan Kataria
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Mumbai, India
| | - Nidhi Bidyut Panda
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Luthra
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shalvi Mahajan
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Soni
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Narender Kaloria
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shamik Paul
- Department of Anaesthesiology and Critical Care, Armed Forces Medical College (AFMC), Pune, India
| | - Summit Bloria
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shailesh Gupta
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Chhabra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
218
|
Muraoka S, Asai T, Fukui T, Ota S, Shimato S, Koketsu N, Nishizawa T, Araki Y, Saito R. Real-world data of clazosentan in combination therapy for aneurysmal subarachnoid hemorrhage: a multicenter retrospective cohort study. Neurosurg Rev 2023; 46:195. [PMID: 37555872 DOI: 10.1007/s10143-023-02104-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 08/10/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm, significantly associated with morbidity and mortality. In double-blind, placebo-controlled phase 3 studies, clazosentan reduces cerebral vasospasm-related morbidity and all-cause mortality in patients with aSAH. There are no reports about the clinical efficacy of clazosentan combination therapy with some other drugs. Initially, we explored the efficacy of clazosentan combination therapy with cilostazol, statin, and antiepileptic drugs. Subsequently, we assessed the add-on effect of fasudil to clazosentan combination therapy for aSAH patients. This multicenter, retrospective, observational cohort study included Japanese patients with aSAH between June 2022 and March 2023. The primary outcome was the ordinal score on the modified Rankin Scale (mRS; range, 0-6, with elevated scores indicating greater disability) at discharge. Among the 47 cases (women 74.5%; age 64.4 ± 15.0 years) undergoing clazosentan combination therapy, 29 (61.7%) resulted in favorable outcomes. Overall, vasospasm occurred in 16 cases (34.0%), with four cases (8.5%) developing vasospasm-related delayed cerebral ischemia (DCI). Both hypotension and vasospasm-related DCI were related to unfavorable outcome at discharge. Fasudil were added in 18 (38.3%) cases. Despite adding fasudil to clazosentan combination therapy, the incidence of aSAH-related vasospasm did not decrease. Added-on fasudil to combination therapy related to pulmonary edema, vasospasm, and vasospasm-related DCI, and unfavorable outcomes. Clazosentan combination therapy could potentially result in favorable outcomes for aSAH patients to prevent post-aSAH vasospasm-related DCI. The add-on effect of fasudil to combination therapy did not demonstrate a significant impact in reducing aSAH-related vasospasm or improving outcomes at discharge.
Collapse
Affiliation(s)
- Shinsuke Muraoka
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan.
| | - Takumi Asai
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Takahiko Fukui
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Shinji Ota
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Shinji Shimato
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Naoki Koketsu
- Department of Neurosurgery, Tosei General Hospital, Seto, Aichi, Japan
| | - Toshihisa Nishizawa
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Yoshio Araki
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| |
Collapse
|
219
|
Shimizu S, Hanai T, Egashira Y, Sato Y, Sekiya K, Nishida S, Ishihara M, Ishihara T, Asada R, Kobayashi R, Suzuki A. Controlling nutritional status score during hospitalization as a predictor of clinical outcome in patients with aneurysmal subarachnoid hemorrhage. Sci Rep 2023; 13:12758. [PMID: 37550344 PMCID: PMC10406813 DOI: 10.1038/s41598-023-39938-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 08/02/2023] [Indexed: 08/09/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a serious condition with high mortality and a high permanent disability rate. In this study, we examined the association of clinical outcome with the Controlling Nutritional Status (CONUT) score during hospitalization in aSAH patients. A single-center, retrospective observational study was conducted at Gifu University Hospital. Patients transported to the emergency room for aSAH and diagnosed with World Federation of Neurosurgical Societies (WFNS) grade III and IV aSAH between April 2004 and March 2021 were enrolled. A logistic regression model was constructed to evaluate the association of the CONUT score with a modified Rankin scale (mRS) ≥ 3 and delayed cerebral ischemia (DCI). 127 patients diagnosed with WFNS grade III and IV aSAH were analyzed. CONUT score was significantly associated with mRS ≥ 3 during hospitalization. The score obtained by subtracting the CONUT score at admission from the maximum CONUT score was significantly associated with mRS ≥ 3 at discharge. Moreover, the score obtained by subtracting the CONUT score at admission from the maximum CONUT score during the first 14 days was significantly associated with DCI within 14 days from admission. These findings indicate that CONUT score during hospitalization may be a useful daily marker for predicting poor outcomes in aSAH patients.
Collapse
Affiliation(s)
- Shinya Shimizu
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tatsunori Hanai
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Yusuke Egashira
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yukina Sato
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Kumiko Sekiya
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Shohei Nishida
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Masashi Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Ryuta Asada
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Ryo Kobayashi
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
- Laboratory of Advanced Medical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan.
- Laboratory of Advanced Medical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan.
| |
Collapse
|
220
|
Chen YT, Wu MR, Li ZX, Gu HQ, Zhou Q, Wang DD, Wang YJ, Xing-Quan Zhao. Assessment of rehabilitation following subarachnoid haemorrhage in China: findings from the Chinese Stroke Center Alliance. BMC Neurol 2023; 23:291. [PMID: 37542260 PMCID: PMC10403933 DOI: 10.1186/s12883-023-03349-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 07/28/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Rehabilitation improves functional recovery in subarachnoid hemorrhage (SAH) patients, and assessing patients for rehabilitation is the first step in this process. However, little is known about clinical practice in China regarding the assessment and provision of rehabilitation for patients with SAH. METHODS To identify patients hospitalized with SAH and to analyze rehabilitation assessment rates, we used data for 11,234 SAH patients admitted to 861 hospitals from the China Stroke Center Alliance from August 2015 to July 2019. We examined factors for rehabilitation assessment and analyzed the relationship between rehabilitation assessment and outcomes in these patients. RESULTS Among 11,234 patients with SAH, 6,513 (58.0%) were assessed for rehabilitation. Assessed patients had an increased length of stay (mean ± SD days: 17.3 ± 12.5 versus 11.6 ± 10.5, P = 49.4), a higher Glasgow Coma Scale (GCS) score on admission (mean ± SD GCS score: 12.3 ± 3.8 versus 11.8 ± 4.4, P = 12.2), and were more likely to be admitted to the stroke unit (19.6% versus 13.8%, P = 15.6). In multivariable analysis, factors associated with an increased likelihood of a rehabilitation assessment (p < 0.05) included a longer length of stay (odds ratio [OR], 1.04; 95% confidence interval (CI), 1.04 to 1.05) and care such as dysphagia screening (OR, 1.88; 95% CI, 1.73 to 2.04), DVT prophylaxis (OR, 1.56; 95% CI, 1.41 to 1.72) and vessel evaluation (OR, 1.80; 95% CI, 1.63 to 1.98). For the multivariate analysis of outcomes, patients undergoing rehabilitation assessment had a longer length of stay (OR, 1.96; 95% CI, 1.81 to 2.12), a higher modified Rankin Scale (mRS) score at discharge (OR, 1.49; 95% CI, 1.36 to 1.64), and higher rates of discharge to a rehabilitation center (OR, 3.23; 95% CI, 1.81-5.75). CONCLUSION More than two-fifths of SAH patients were not assessed for rehabilitation. Rates vary considerably among hospital grades, and there is a need to improve adherence to recommended care for SAH patients.
Collapse
Affiliation(s)
- Yi-Tong Chen
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Vascular Neurology Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mei-Ru Wu
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Vascular Neurology Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zi-Xiao Li
- Department of Neurology, Vascular Neurology Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qi Zhou
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dan-Dan Wang
- Department of Neurology, Vascular Neurology Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong-Jun Wang
- Department of Neurology, Vascular Neurology Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Xing-Quan Zhao
- Department of Neurology, Vascular Neurology Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Department of Neurology, Fengtai District, National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4Th Ring West Rd, Beijing, 100070, China.
| |
Collapse
|
221
|
Terrett LA, McIntyre L, Turgeon AF, English SW. Anemia and Red Blood Cell Transfusion in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:91-103. [PMID: 37634181 DOI: 10.1007/s12028-023-01815-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 08/29/2023]
Abstract
Anemia is very common in aneurysmal subarachnoid hemorrhage (aSAH), with approximately half of the aSAH patient population developing moderate anemia during their hospital stay. The available evidence (both physiologic and clinical) generally supports an association of anemia with unfavorable outcomes. Although aSAH shares a number of common mechanisms of secondary insult with other forms of acute brain injury, aSAH also has specific features that make it unique: an early phase (in which early brain injury predominates) and a delayed phase (in which delayed cerebral ischemia and vasospasm predominate). The effects of both anemia and transfusion are potentially variable between these phases, which may have unique considerations and possibly different risk-benefit profiles. Data on transfusion in this population are almost exclusively limited to observational studies, which suffer from significant heterogeneity and risk of bias. Overall, the results are conflicting, with the balance of the studies suggesting that transfusion is associated with unfavorable outcomes. The transfusion targets that are well established in other critically ill populations should not be automatically applied to patients with aSAH because of the unique disease characteristics of this population and the limited representation of aSAH in the clinical trials that established these targets. There are two upcoming clinical trials evaluating transfusion in aSAH that should help clarify specific transfusion targets. Until then, it is reasonable to base transfusion decisions on the current guidelines and use an individualized approach incorporating physiologic and clinical data when available.
Collapse
Affiliation(s)
- Luke A Terrett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
- Department of Adult Critical Care, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute (OHRI), Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Unit, Centre hospitalier universitaire de Québec-Université Laval Research Center, Quebec City, QC, Canada
| | - Shane W English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute (OHRI), Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
- The Ottawa Hospital, Ottawa, ON, Canada.
| |
Collapse
|
222
|
Vergouwen MDI, Rinkel GJE. Emergency Medical Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:51-58. [PMID: 37344653 PMCID: PMC10499704 DOI: 10.1007/s12028-023-01757-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/08/2023] [Indexed: 06/23/2023]
Abstract
Aneurysmal subarachnoid hemorrhage is a medical emergency that necessitates direct transfer to a tertiary referral center specialized in the diagnosis and treatment of this condition. The initial hours after aneurysmal rupture are critical for patients with aneurysmal subarachnoid hemorrhage, both in terms of rebleeding and combating the effect of early brain injury. No good treatment options are available to reduce the risk of rebleeding before aneurysm occlusion. Lowering the blood pressure may reduce the risk of rebleeding but carries a risk of inducing delayed cerebral ischemia or aggravating the consequences of early brain injury. Early brain injury after aneurysmal rupture has an important effect on final clinical outcome. Proper cerebral perfusion is pivotal in these initial hours after aneurysmal rupture but threatened by complications such as neurogenic pulmonary edema and cardiac stunning, or by acute hydrocephalus, which may necessitate early drainage of cerebrospinal fluid.
Collapse
Affiliation(s)
- Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
223
|
Ebel F, Lichter E, Mariani L, Guzman R, Soleman J. Rapid Versus Gradual Weaning of External Ventricular Drain: A Systematic Literature Review and Meta-analysis. Neurocrit Care 2023; 39:250-259. [PMID: 37308728 PMCID: PMC10499951 DOI: 10.1007/s12028-023-01766-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/19/2023] [Indexed: 06/14/2023]
Abstract
The insertion of an external ventricular drain (EVD) is one of the most common neurosurgical procedures. Whether the weaning method (gradual or rapid) influences the ventriculoperitoneal shunt (VPS) insertion rate has not been conclusively established. The aim of this study is to provide a systematic literature review and conduct a meta-analysis of studies comparing gradual with rapid EVD weaning regarding VPS insertion rate. Articles were identified by searching the Pubmed/Medline, Embase, and Web of Science databases throughout October 2022. Two independent researchers assessed the studies for inclusion and quality. We included randomized trials, prospective cohort studies, and retrospective cohort studies, which compared gradual and rapid EVD weaning. The primary outcome was VPS insertion rate, whereas secondary outcomes were EVD-associated infection (EVDAI) rate and length of stay in the hospital and intensive care unit (ICU). Four studies directly comparing rapid versus gradual EVD weaning, with 1337 patients suffering from subarachnoid hemorrhage, were identified and included in the meta-analysis. VPS insertion rate was 28.1% and 32.1% in patients with gradual and rapid EVD weaning, respectively (relative risk 0.85, 95% confidence interval 0.49-1.46, p = 0.56). Further, the EVDAI rate was comparable between the groups (gradual group 11.2%, rapid group 11.5%, relative risk 0.67, 95% confidence interval 0.24-1.89, p = 0.45), whereas length of stay in the ICU and hospital were significantly shorter in the rapid weaning group (2.7 and 3.6 days, respectively; p < 0.01). Rapid EVD weaning seems comparable to gradual EVD weaning concerning VPS insertion rates and EVDAI, whereas hospital and ICU length of stay is significantly reduced.
Collapse
Affiliation(s)
- Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Eric Lichter
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
| |
Collapse
|
224
|
Johnston JC, Sartwelle TP. Medical Malpractice and the Neurologist: Specific Neurological Claims. Neurol Clin 2023; 41:493-512. [PMID: 37407102 DOI: 10.1016/j.ncl.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
This chapter highlights the most frequently encountered neurological malpractice claims. The format is designed to provide a rudimentary understanding of how lawsuits arise and thereby focus discussion on adapting practice patterns to improve patient care and minimize liability risk.
Collapse
Affiliation(s)
- James C Johnston
- GlobalNeurology, 17B Farnham Street, Auckland 1052, New Zealand; GlobalNeurology®, 5290 Medical Drive, San Antonio, TX 78229, USA.
| | - Thomas P Sartwelle
- Hicks Davis Wynn, PC, 3555 Timmons Lane, Suite 1000, Houston, TX 77027, USA
| |
Collapse
|
225
|
Salvagno M, Gouvea Bogossian E, Halenarova K, Ego A, Taccone FS. Cervical Ganglion Sympathectomy to Treat Cerebral Vasospasm in Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:241-249. [PMID: 36828982 DOI: 10.1007/s12028-023-01694-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 02/26/2023]
Abstract
Delayed cerebral ischemia (DCI) is still a significant cause of death and disability after aneurysmal subarachnoid hemorrhage. Cerebral vasospasm represents one of the most reported mechanisms associated with DCI. The management of DCI-related vasospasm remains a significant challenge for clinicians; induced hypertension, intraarterial vasodilators, and/or intracranial vessel angioplasty-particularly in refractory or recurrent cases-are the most used therapies. Because an essential role in the pathophysiology of cerebral vasospasm has been attributed to the adrenergic sympathetic nerves, a "sympatholytic" intervention, consisting of a temporary interruption of the sympathetic pathways using local anesthetics, has been advocated to minimize the vascular narrowing and reverse the consequences of cerebral vasospasm on tissue perfusion. In this review, we have analyzed the existing literature on the block of the cervical ganglions, particularly the stellate ganglion, in managing refractory cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. These findings could help clinicians to understand the potential role of such intervention and to develop future interventional trials in this setting.
Collapse
Affiliation(s)
- Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium.
| | | | - Katarina Halenarova
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Amedée Ego
- Department of Intensive Care, Hôpitaux Iris Sud, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| |
Collapse
|
226
|
Deem S, Diringer M, Livesay S, Treggiari MM. Hemodynamic Management in the Prevention and Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:81-90. [PMID: 37160848 DOI: 10.1007/s12028-023-01738-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023]
Abstract
One of the most serious complications after subarachnoid hemorrhage (SAH) is delayed cerebral ischemia, the cause of which is multifactorial. Delayed cerebral ischemia considerably worsens neurological outcome and increases the risk of death. The targets of hemodynamic management of SAH have widely changed over the past 30 years. Hypovolemia and hypotension were favored prior to the era of early aneurysmal surgery but were subsequently replaced by the use of hypervolemia and hypertension. More recently, the concept of goal-directed therapy targeting euvolemia, with or without hypertension, is gaining preference. Despite the evolving concepts and the vast literature, fundamental questions related to hemodynamic optimization and its effects on cerebral perfusion and patient outcomes remain unanswered. In this review, we explain the rationale underlying the approaches to hemodynamic management and provide guidance on contemporary strategies related to fluid administration and blood pressure and cardiac output manipulation in the management of SAH.
Collapse
Affiliation(s)
- Steven Deem
- Neurocritical Care Unit, Swedish Medical Center, Seattle, WA, USA.
| | - Michael Diringer
- Department of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Sarah Livesay
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
- College of Nursing, Rush University, Chicago, IL, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical School, Durham, NC, USA
| |
Collapse
|
227
|
Svedung Wettervik T, Hånell A, Ronne-Engström E, Lewén A, Enblad P. Temperature Changes in Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Relation to Injury Pattern, Intracranial Pressure Dynamics, Cerebral Energy Metabolism, and Clinical Outcome. Neurocrit Care 2023; 39:145-154. [PMID: 36922474 PMCID: PMC10499919 DOI: 10.1007/s12028-023-01699-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/13/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND The aim was to study the course of body temperature in the acute phase of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) in relation to the primary brain injury, cerebral physiology, and clinical outcome. METHODS In this observational study, 166 patients with aSAH treated at the neurosurgery department at Uppsala University Hospital in Sweden between 2008 and2018 with temperature, intracranial pressure (ICP), and microdialysis (MD) monitoring were included. The first 10 days were divided into the early phase (days 1-3) and the vasospasm phase (days 4-10). RESULTS Normothermia (temperature = 36-38 °C) was most prevalent in the early phase. A lower mean temperature at this stage was univariately associated with a worse primary brain injury, with higher Fisher grade and higher MD glycerol concentration, as well as a worse neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the early phase. There was a transition toward an increased burden of hyperthermia (temperature > 38 °C) in the vasospasm phase. This was associated with concurrent infections but not with neurological or radiological injury severity at admission. Elevated temperature was associated with higher MD pyruvate concentration, lower rate of an MD pattern indicative of ischemia, and higher rate of poor neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the vasospasm phase. The associations between temperature and clinical outcome did not hold true in multiple logistic regression analyses. CONCLUSIONS Spontaneously low temperature in the early phase reflected a worse primary brain injury and indicated a worse outcome prognosis. Hyperthermia was common in the vasospasm phase and was more related to infections than primary injury severity but also with a more favorable energy metabolic pattern with better substrate supply, possibly related to hyperemia.
Collapse
Affiliation(s)
- Teodor Svedung Wettervik
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden.
| | - Anders Hånell
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
| |
Collapse
|
228
|
Gouvêa Bogossian E, Blandino Ortiz A, Esposito V, Caricato A, Righy Shinotsuka C, Monléon Lopez B, Giannì G, Macchini E, de Pablo Sanchez R, Pisapia L, Turon R, Gonçalves B, Badenes R, Kurtz P, Taccone FS. Neurological Pupil Index and Delayed Cerebral Ischemia after Subarachnoid Hemorrhage: A Retrospective Multicentric Study. Neurocrit Care 2023; 39:116-124. [PMID: 37225941 DOI: 10.1007/s12028-023-01744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/24/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) occurs in around 30% of patients suffering from nontraumatic subarachnoid hemorrhage (SAH) and is associated with poor neurological outcome. Whether the Neurological Pupil index (NPi) derived from the automated pupillometry could help to diagnose the occurrence of DCI remains unknown. The aim of this study was to investigate the association of NPi with the occurrence of DCI in patients with SAH. METHODS This was a multicenter, retrospective cohort study of consecutive patients with SAH admitted to the intensive care units of five hospitals between January 2018 and December 2020 who underwent daily NPi recordings (every 8 h) during the first 10 days of admission. DCI was diagnosed according to standard definitions (in awake patients) or based on neuroimaging and neuromonitoring (in sedated or unconscious patients). An NPi < 3 was defined as abnormal. The primary outcome of the study was to assess the time course of daily NPi between patients with DCI and patients without DCI. Secondary outcome included the number of patients who had an NPi < 3 before DCI. RESULTS A total of 210 patients were eligible for the final analysis; DCI occurred in 85 (41%) patients. Patients who developed DCI had similar values of mean and worst daily NPi over time when compared with patients without DCI. Patients with DCI had a higher proportion of at least one NPi < 3 at any moment before DCI when compared with others (39/85, 46% vs. 35/125, 38%, p = 0.009). Similarly, the worst NPi before DCI diagnosis was lower in the DCI group when compared with others (3.1 [2.5-3.8] vs. 3.7 [2.7-4.1], p = 0.05). In the multivariable logistic regression analysis, the presence of NPi < 3 was not independently associated with the development of DCI (odds ratio 1.52 [95% confidence interval 0.80-2.88]). CONCLUSIONS In this study, NPi measured three times a day and derived from the automated pupillometry had a limited value for the diagnosis of DCI in patients with SAH.
Collapse
Affiliation(s)
- Elisa Gouvêa Bogossian
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Aaron Blandino Ortiz
- Intensive Care Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Departament of Medicine and Medical Specialties, University of Alcalá, Madrid, Spain
| | - Valentina Esposito
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Anselmo Caricato
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cassia Righy Shinotsuka
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Laboratório de Medicina Intensiva, Fundação Oswaldo Cruz, Instituto Nacional de Infectologia, Rio de Janeiro, Brazil
| | - Berta Monléon Lopez
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Giuseppina Giannì
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisabetta Macchini
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Raúl de Pablo Sanchez
- Intensive Care Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Departament of Medicine and Medical Specialties, University of Alcalá, Madrid, Spain
| | - Luca Pisapia
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ricardo Turon
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Bruno Gonçalves
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
- INCLIVA Health Research Institute, Valencia, Spain
| | - Pedro Kurtz
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- D'Or Institute of Research and Education, Rio de Janeiro, Brazil
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| |
Collapse
|
229
|
Gempeler A, Gaviria L, Ortiz A, Jaramillo N, Beltrán L, Escobar S, Rondón M, Rosselli D, Martinez-Buitrago JE, Mejía-Mantilla JH. Effect of an Albumin Infusion Treatment Protocol on Delayed Cerebral Ischemia and Relevant Outcomes in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:180-190. [PMID: 37231237 DOI: 10.1007/s12028-023-01731-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 04/06/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND An institutional management protocol for patients with subarachnoid hemorrhage (SAH) based on initial cardiac assessment, permissiveness of negative fluid balances, and use of a continuous albumin infusion as the main fluid therapy for the first 5 days of the intensive care unit (ICU) stay was implemented at our hospital in 2014. It aimed at achieving and maintaining euvolemia and hemodynamic stability to prevent ischemic events and complications in the ICU by reducing periods of hypovolemia or hemodynamic instability. This study aimed at assessing the effect of the implemented management protocol on the incidence of delayed cerebral ischemia (DCI), mortality, and other relevant outcomes in patients with SAH during ICU stay. METHODS We conducted a quasi-experimental study with historical controls based on electronic medical records of adults with SAH admitted to the ICU at a tertiary care university hospital in Cali, Colombia. The patients treated between 2011 and 2014 were the control group, and those treated between 2014 and 2018 were the intervention group. We collected baseline clinical characteristics, cointerventions, occurrence of DCI, vital status after 6 months, neurological status after 6 months, hydroelectrolytic imbalances, and other SAH complication. Multivariable and sensitivity analyses that controlled for confounding and considered the presence of competing risks were used to adequately estimate the effects of the management protocol. The study was approved by our institutional ethics review board before study start. RESULTS One hundred eighty-nine patients were included for analysis. The management protocol was associated with a reduced incidence of DCI (hazard ratio 0.52 [95% confidence interval 0.33-0.83] from multivariable subdistribution hazards model) and hyponatremia (relative risk 0.55 [95% confidence interval 0.37-0.80]). The management protocol was not associated with higher hospital or long-term mortality, nor with a higher occurrence of other unfavorable outcomes (pulmonary edema, rebleeding, hydrocephalus, hypernatremia, pneumonia). The intervention group also had lower daily and cumulative administered fluids compared with historic controls (p < 0.0001). CONCLUSIONS A management protocol based on hemodynamically oriented fluid therapy in combination with a continuous albumin infusion as the main fluid during the first 5 days of the ICU stay appears beneficial for patients with SAH because it was associated with reduced incidence of DCI and hyponatremia. Proposed mechanisms include improved hemodynamic stability that allows euvolemia and reduces the risk of ischemia, among others.
Collapse
Affiliation(s)
- Andrés Gempeler
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia.
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Cali, Colombia.
| | - Leidy Gaviria
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Alejandra Ortiz
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia
| | | | | | | | - Martín Rondón
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Cali, Colombia
| | - Diego Rosselli
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Cali, Colombia
| | | | - Jorge H Mejía-Mantilla
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia
- Department of Intensive Care Medicine, Fundación Valle del Lili, Cali, Colombia
| |
Collapse
|
230
|
Rass V, Kindl P, Lindner A, Kofler M, Altmann K, Putnina L, Ianosi BA, Schiefecker AJ, Beer R, Pfausler B, Helbok R. Blood Pressure Changes in Association with Nimodipine Therapy in Patients with Spontaneous Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:104-115. [PMID: 37308727 PMCID: PMC10499738 DOI: 10.1007/s12028-023-01760-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/16/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Nimodipine is recommended to prevent delayed cerebral ischemia in patients with spontaneous subarachnoid hemorrhage (SAH). Here, we studied hemodynamic side effects of different nimodipine formulations (per os [PO] and intravenous [IV]) in patients with SAH undergoing continuous blood pressure monitoring. METHODS This observational cohort study includes consecutive patients with SAH (271 included in the IV group, 49 in the PO group) admitted to a tertiary care center between 2010 and 2021. All patients received prophylactic IV or PO nimodipine. Hemodynamic responses were evaluated based on median values within the first hour after continuous IV nimodipine initiation or PO nimodipine application (601 intakes within 15 days). Significant changes were defined as > 10% drop in systolic blood pressure (SBP) or diastolic blood pressure from baseline (median values 30 min before nimodipine application). With the use of multivariable logistic regression, risk factors associated with SBP drops were identified. RESULTS Patients were admitted with a median Hunt & Hess score of 3 (2-5; IV 3 [2-5], PO 1 [1-2], p < 0.001) and were 58 (49-69) years of age. Initiation of IV nimodipine was associated with a > 10% SBP drop in 30% (81/271) of patients, with a maximum effect after 15 min. A start or increase in noradrenaline was necessary in 136/271 (50%) patients, and colloids were administered in 25/271 (9%) patients within 1 h after IV nimodipine initiation. SBP drops > 10% occurred after 53/601 (9%) PO nimodipine intakes, with a maximum effect after 30-45 min in 28/49 (57%) patients. Noradrenaline application was uncommon (3% before and 4% after nimodipine PO intake). Hypotensive episodes to an SBP < 90 mm Hg were not observed after IV or PO nimodipine application. In multivariable analysis, only a higher SBP at baseline was associated with a > 10% drop in SBP after IV (p < 0.001) or PO (p = 0.001) nimodipine application, after adjusting for the Hunt & Hess score on admission, age, sex, mechanical ventilation, days after intensive care unit admission, and delayed cerebral ischemia. CONCLUSIONS Significant drops in SBP occur in one third of patients after the start of IV nimodipine and after every tenth PO intake. Early recognition and counteracting with vasopressors or fluids seems necessary to prevent hypotensive episodes.
Collapse
Affiliation(s)
- Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Philipp Kindl
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Klaus Altmann
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lauma Putnina
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bogdan-Andrei Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| |
Collapse
|
231
|
Busl KM, Rabinstein AA. Prevention and Correction of Dysnatremia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:70-80. [PMID: 37138158 DOI: 10.1007/s12028-023-01735-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/12/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Dysnatremia occurs commonly in patients with aneurysmal subarachnoid hemorrhage (aSAH). The mechanisms for development of sodium dyshomeostasis are complex, including the cerebral salt-wasting syndrome, the syndrome of inappropriate secretion of antidiuretic hormone, diabetes insipidus. Iatrogenic occurrence of altered sodium levels plays a role, as sodium homeostasis is tightly linked to fluid and volume management. METHODS Narrative review of the literature. RESULTS Many studies have aimed to identify factors predictive of the development of dysnatremia, but data on associations between dysnatremia and demographic and clinical variables are variable. Furthermore, although a clear relationship between serum sodium serum concentrations and outcomes has not been established-poor outcomes have been associated with both hyponatremia and hypernatremia in the immediate period following aSAH and set the basis for seeking interventions to correct dysnatremia. While sodium supplementation and mineralocorticoids are frequently administered to prevent or counter natriuresis and hyponatremia, evidence to date is insufficient to gauge the effect of such treatment on outcomes. CONCLUSIONS In this article, we reviewed available data and provide a practical interpretation of these data as a complement to the newly issued guidelines for management of aSAH. Gaps in knowledge and future directions are discussed.
Collapse
Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA.
| | | |
Collapse
|
232
|
Hofmann BB, Donaldson DM, Fischer I, Karadag C, Neyazi M, Piedade GS, Abusabha Y, Muhammad S, Rubbert C, Hänggi D, Beseoglu K. Blood Pressure Affects the Early CT Perfusion Imaging in Patients with aSAH Reflecting Early Disturbed Autoregulation. Neurocrit Care 2023; 39:125-134. [PMID: 36802010 PMCID: PMC10499698 DOI: 10.1007/s12028-023-01683-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/26/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early computed tomography perfusion (CTP) is frequently used to predict delayed cerebral ischemia following aneurysmatic subarachnoid hemorrhage (aSAH). However, the influence of blood pressure on CTP is currently controversial (HIMALAIA trial), which differs from our clinical observations. Therefore, we aimed to investigate the influence of blood pressure on early CTP imaging in patients with aSAH. METHODS We retrospectively analyzed the mean transit time (MTT) of early CTP imaging within 24 h after bleeding prior to aneurysm occlusion with respect to blood pressure shortly before or after the examination in 134 patients. We correlated the cerebral blood flow with the cerebral perfusion pressure in the case of patients with intracranial pressure measurement. We performed a subgroup analysis of good-grade (World Federation of Neurosurgical Societies [WFNS] I-III), poor-grade (WFNS IV-V), and solely WFNS grade V aSAH patients. RESULTS Mean arterial pressure (MAP) significantly correlated inversely with the mean MTT in early CTP imaging (R = - 0.18, 95% confidence interval [CI] - 0.34 to - 0.01, p = 0.042). Lower mean blood pressure was significantly associated with a higher mean MTT. Subgroup analysis revealed an increasing inverse correlation when comparing WFNS I-III (R = - 0.08, 95% CI - 0.31 to 0.16, p = 0.53) patients with WFNS IV-V (R = - 0.2, 95% CI - 0.42 to 0.05, p = 0.12) patients, without reaching statistical significance. However, if only patients with WFNS V are considered, a significant and even stronger correlation between MAP and MTT (R = - 0.4, 95% CI - 0.65 to 0.07, p = 0.02) is observed. In patients with intracranial pressure monitoring, a stronger dependency of cerebral blood flow on cerebral perfusion pressure is observed for poor-grade patients compared with good-grade patients. CONCLUSIONS The inverse correlation between MAP and MTT in early CTP imaging, increasing with the severity of aSAH, suggests an increasing disturbance of cerebral autoregulation with the severity of early brain injury. Our results emphasize the importance of maintaining physiological blood pressure values in the early phase of aSAH and preventing hypotension, especially in patients with poor-grade aSAH.
Collapse
Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Guilherme S Piedade
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
233
|
Rynkowski CB, Hegele V, Soares PHR, Tonello ML, Petterson L, Gomes FK, Rabinstein AA, Bastos LSL, Turon R, Gonçalves B, Righy C, Bozza FA, Kurtz P. Effects of Tranexamic Acid in Patients with Subarachnoid Hemorrhage in Brazil: A Prospective Observational Study with Propensity Score Analysis. Neurocrit Care 2023; 39:191-197. [PMID: 37131089 DOI: 10.1007/s12028-023-01732-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 04/06/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Rebleeding from a ruptured aneurysm increases the risk of unfavorable outcomes after subarachnoid hemorrhage (SAH) and is prevented by early aneurysm occlusion. The role of antifibrinolytics before aneurysm obliteration remains controversial. We investigated the effects of tranexamic acid on long-term functional outcomes of patients with aneurysmal SAH (aSAH). METHODS This was a single-center, prospective, observational study conducted in a high-volume tertiary hospital in a middle-income country from December 2016 to February 2020. We included all consecutive patients with aSAH who either received or did not receive tranexamic acid (TXA) treatment. Multivariate logistic regression analysis using propensity score was used to evaluate the association of TXA use with long-term functional outcomes, measured by the modified Rankin Scale (mRS) at 6 months. RESULTS A total of 230 patients with aSAH were analyzed. The median (interquartile range) age was 55 (46-63) years, 72% were women, 75% presented with good clinical grade (World Federation of Neurological Surgeons grade 1-3), and 83% had a Fisher scale of 3 or 4. Around 80% of patients were admitted up to 72 h from ictus. The aneurysm occlusion method was surgical clipping in 80% of the patients. A total of 129 patients (56%) received TXA. In multivariable logistic regression using inverse probability treatment weighting, the long-term rate of unfavorable outcomes (modified Rankin scale 4-6) was the same in the TXA and non-TXA groups (61 [48%] in TXA group vs. 33 [33%] in non-TXA group; odds ratio [OR] 1.39, 95% confidence interval [CI] 0.67-2.92; p = 0.377). The TXA group had higher in-hospital mortality (33 vs. 11% in non-TXA group; OR 4.13, 95% CI 1.55-12.53, p = 0.007). There were no differences between the groups concerning intensive care unit length of stay (16 ± 11.22 days in TXA group vs. 14 ± 9.24 days in non-TXA group; p = 0.2) or hospital (23 ± 13.35 days in TXA group vs. 22 ± 13.36 days in non-TXA group; p = 0.9). There was no difference in the rates of rebleeding (7.8% in TXA group vs. 8.9% in non-TXA group; p = 0.31) or delayed cerebral ischemia (27% in TXA group vs. 19% in non-TXA group; p = 0.14). For the propensity-matched analysis, 128 individuals were selected (64 in TXA group and 64 in non-TXA group), and the rates of unfavorable outcomes at 6 months were also similar between groups (45% in TXA group and 36% in non-TXA group; OR 1.22, 95% CI 0.51-2.89; p = 0.655). CONCLUSIONS Our findings in a cohort with delayed aneurysm treatment reinforce previous data that TXA use before aneurysm occlusion does not improve functional outcomes in aSAH.
Collapse
Affiliation(s)
- Carla B Rynkowski
- Intensive Care Unit, Cristo Redentor Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Ernesto Dornelles Hospital, Porto Alegre, Brazil
| | - Vanessa Hegele
- Pharmacy Department, Cristo Redentor Hospital, Porto Alegre, Brazil
| | | | | | | | | | | | - Leonardo S L Bastos
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Ricardo Turon
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Bruno Gonçalves
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Cassia Righy
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
- D ́Or Institute for Research and Education, Rua Diniz Cordeiro 30, Rio de Janeiro, RJ, 22281-100, Brazil
| | - Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
- D ́Or Institute for Research and Education, Rua Diniz Cordeiro 30, Rio de Janeiro, RJ, 22281-100, Brazil.
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil.
| |
Collapse
|
234
|
Metayer T, Dumot C, Bernard F, Le Reste PJ, Bernat AL, Cebula H, Mallereau CH, Peltier C, le Guerinel C, Vivien D, Piotin M, Emery E, Gillard V, Leclerc A, Magro E, Proust F, Pelissou-Guyotat I, Derrey S, Aldea S, Barbier C, Borha A, Nadin L, Briant AR, Gaberel T. Clipping Versus Coiling for Ruptured MCA Aneurysms Associated with Intracerebral Hematoma Requiring Surgical Evacuation. Neurocrit Care 2023; 39:162-171. [PMID: 36991178 DOI: 10.1007/s12028-023-01702-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/14/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Ruptured middle cerebral artery aneurysm (MCAa) can lead to intracerebral hematoma, and surgical evacuation can be performed in these cases. MCAa can be treated by clipping or before by endovascular therapy (EVT). Our objective was to compare the impact on the functional outcome of MCAa in patients with intracerebral hematoma requiring evacuation. METHODS This is a multicenter, retrospective, cohort study with nine French neurosurgical units from January 1, 2013, to December 31, 2020. All participants were adult patients who required evacuation of an intracerebral hematoma. We looked for risk factors for poor outcomes by comparing the baseline characteristics and treatments performed by using the 6-month modified Rankin scale score. Poor outcomes were defined by an modified Rankin scale score of 3-6. RESULTS A total of 162 patients were included. A total of 129 (79.6%) patients were treated by microsurgery, and 33 (20.4%) patients were treated by EVT. In multivariate analysis, factors associated with poor outcomes included hematoma volume, realization of a decompressive craniectomy, occurrence of procedure-related symptomatic cerebral ischemia, occurrence of delayed cerebral ischemia, and EVT. In the propensity score matching analysis (n = 33 per group), poor outcomes were observed in 30% of the patients in the clipping group versus 76% in the EVT group (P < 0.001). These differences may have been related to a longer delay between hospital admission and hematoma evacuation in the EVT group. CONCLUSIONS In the specific subgroup of ruptured MCAa with intracerebral hematoma that requires surgical evacuation, clipping with concomitant hematoma evacuation could provide better functional outcomes than EVT followed by surgical evacuation.
Collapse
Affiliation(s)
- Thomas Metayer
- Department of Neurosurgery, University Hospital of Caen, Caen, France.
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France.
- Service de Neurochirurgie, CHU de Caen, Avenue de la Côte de Nacre, 14000, Caen, France.
| | - Chloe Dumot
- Department of Neurosurgery, Hospices Civils de Lyon, Lyon, France
| | - Florian Bernard
- Department of Neurosurgery, University Hospital of Angers, Angers, France
| | | | - Anne-Laure Bernat
- Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France
| | - Helene Cebula
- Department of Neurosurgery, University Hospital of Strasbourg, Strasbourg, France
| | | | - Charles Peltier
- Department of Neurosurgery, University Hospital of Brest, Brest, France
| | | | - Denis Vivien
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France
| | - Michel Piotin
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Evelyne Emery
- Department of Neurosurgery, University Hospital of Caen, Caen, France
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France
| | - Vianney Gillard
- Department of Neuroradiology, University Hospital of Rouen, Rouen, France
| | - Arthur Leclerc
- Department of Neurosurgery, University Hospital of Caen, Caen, France
| | - Elsa Magro
- Department of Neurosurgery, University Hospital of Brest, Brest, France
| | - Francois Proust
- Department of Neurosurgery, University Hospital of Strasbourg, Strasbourg, France
| | | | - Stephane Derrey
- Department of Neuroradiology, University Hospital of Rouen, Rouen, France
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Charlotte Barbier
- Department of Neuroradiology, University Hospital of Caen, Caen, France
| | - Alin Borha
- Department of Neurosurgery, University Hospital of Caen, Caen, France
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France
| | - Lawrence Nadin
- Biostatistics and Clinical Research Unit, University Hospital of Caen Normandy, Caen, France
| | - Anais R Briant
- Biostatistics and Clinical Research Unit, University Hospital of Caen Normandy, Caen, France
| | - Thomas Gaberel
- Department of Neurosurgery, University Hospital of Caen, Caen, France
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France
| |
Collapse
|
235
|
Wolf S, Mielke D, Barner C, Malinova V, Kerz T, Wostrack M, Czorlich P, Salih F, Engel DC, Ehlert A, Staykov D, Alturki AY, Sure U, Bardutzky J, Schroeder HWS, Schürer L, Beck J, Juratli TA, Fritsch M, Lemcke J, Pohrt A, Meyer B, Schwab S, Rohde V, Vajkoczy P. Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial. JAMA Neurol 2023; 80:833-842. [PMID: 37330974 PMCID: PMC10277935 DOI: 10.1001/jamaneurol.2023.1792] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/31/2023] [Indexed: 06/20/2023]
Abstract
Importance After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome. Objective To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage. Design, Setting, and Participants The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. Intervention A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. Main Outcomes and Measures Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage. Results Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04). Conclusion and Relevance In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage. Trial Registration ClinicalTrials.gov Identifier: NCT01258257.
Collapse
Affiliation(s)
- Stefan Wolf
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Barner
- Department of Anesthesiology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Farid Salih
- Department of Neurology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Doortje C. Engel
- Department of Neurosurgery, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Angelika Ehlert
- Department of Neurosurgery, Asklepios Hospital St Georg, Hamburg, Germany
| | - Dimitre Staykov
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Hospital of the Brothers of St John, Eisenstadt, Austria
| | - Abdulrahman Y. Alturki
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
- Neurovascular Surgery Section, Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Jürgen Bardutzky
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | | | - Ludwig Schürer
- Department of Neurosurgery, Klinikum Bogenhausen, Technical University Munich, Munich, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Inselspital, University of Bern, Switzerland
| | - Tareq A. Juratli
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michael Fritsch
- Department of Neurosurgery, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Anne Pohrt
- Department of Medical Biometrics, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Stefan Schwab
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| |
Collapse
|
236
|
Kofler M, Reitmeir P, Glodny B, Rass V, Lindner A, Ianosi BA, Gaasch M, Schiefecker AJ, Putnina L, Beer R, Rhomberg P, Schmutzhard E, Pfausler B, Helbok R. The Loss of Temporal Muscle Volume is Associated with Poor Outcome in Patients with Subarachnoid Hemorrhage: An Observational Cohort Study. Neurocrit Care 2023; 39:198-206. [PMID: 37308731 PMCID: PMC10499691 DOI: 10.1007/s12028-023-01751-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 05/05/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Intensive care unit (ICU) acquired weakness is a major contributor to poor functional outcome of ICU patients. Quantification of temporal muscle volume assessed on routine computed tomography (CT) scans may serve as a biomarker for muscle wasting in patients suffering from acute brain injury. METHODS This is a retrospective analysis of prospectively collected data. Temporal muscle volume was assessed on head CT scans of consecutive patients with spontaneous subarachnoid hemorrhage within prespecified time frames (on admission, then weekly ± 2 days). Whenever possible, temporal muscle volume was assessed bilaterally and averaged for the analysis. Poor functional outcome was defined as a 3-month modified Rankin Scale Score ≥ 3. Statistical analysis was performed using generalized estimating equations to handle repeated measurements within individuals. RESULTS The analysis comprised 110 patients with a median Hunt & Hess score of 4 (interquartile range 3-5). Median age was 61 (50-70) years, 73 patients (66%) were women. Baseline temporal muscle volume was 18.5 ± 0.78 cm3 and significantly decreased over time (p < 0.001) by a mean of 7.9% per week. Higher disease severity (p = 0.002), hydrocephalus (p = 0.020), pneumonia (p = 0.032), and bloodstream infection (p = 0.015) were associated with more pronounced muscle volume loss. Patients with poor functional outcome had smaller muscle volumes 2 and 3 weeks after subarachnoid hemorrhage compared with those with good outcome (p = 0.025). The maximum muscle volume loss during ICU stay was greater in patients with poor functional outcome (- 32.2% ± 2.5% vs. - 22.7% ± 2.5%, p = 0.008). The hazard ratio for poor functional outcome was 1.027 (95% confidence interval 1.003-1.051) per percent of maximum muscle volume loss. CONCLUSIONS Temporal muscle volume, which is easily assessable on routine head CT scans, progressively decreases during the ICU stay after spontaneous subarachnoid hemorrhage. Because of its association with disease severity and functional outcome, it may serve as a biomarker for muscle wasting and outcome prognostication.
Collapse
Affiliation(s)
- Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Philipp Reitmeir
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bogdan A Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Max Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lauma Putnina
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul Rhomberg
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria.
| |
Collapse
|
237
|
Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
Collapse
Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
| |
Collapse
|
238
|
Addis A, Baggiani M, Citerio G. Intracranial Pressure Monitoring and Management in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:59-69. [PMID: 37280411 PMCID: PMC10499755 DOI: 10.1007/s12028-023-01752-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 05/12/2023] [Indexed: 06/08/2023]
Abstract
Aneurysmal subarachnoid hemorrhage is a medical condition that can lead to intracranial hypertension, negatively impacting patients' outcomes. This review article explores the underlying pathophysiology that causes increased intracranial pressure (ICP) during hospitalization. Hydrocephalus, brain swelling, and intracranial hematoma could produce an ICP rise. Although cerebrospinal fluid withdrawal via an external ventricular drain is commonly used, ICP monitoring is not always consistently practiced. Indications for ICP monitoring include neurological deterioration, hydrocephalus, brain swelling, intracranial masses, and the need for cerebrospinal fluid drainage. This review emphasizes the importance of ICP monitoring and presents findings from the Synapse-ICU study, which supports a correlation between ICP monitoring and treatment with better patient outcomes. The review also discusses various therapeutic strategies for managing increased ICP and identifies potential areas for future research.
Collapse
Affiliation(s)
- Alberto Addis
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Neurological Intensive Care Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | | | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
- Neurological Intensive Care Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy.
| |
Collapse
|
239
|
Gradys A, Szrama J, Molnar Z, Guzik P, Kusza K. Cerebral Perfusion Pressure-Guided Therapy in Patients with Subarachnoid Haemorrhage-A Retrospective Analysis. Life (Basel) 2023; 13:1597. [PMID: 37511972 PMCID: PMC10381919 DOI: 10.3390/life13071597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/21/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Prevention and treatment of haemodynamic instability and increased intracranial pressure (ICP) in patients with subarachnoid haemorrhage (SAH) is vital. This study aimed to evaluate the effects of protocolised cerebral perfusion pressure (CPP)-guided treatment on morbidity and functional outcome in patients admitted to the intensive care unit (ICU) with SAH. METHODS We performed a retrospective study comparing 37 patients who received standard haemodynamic treatment (control group) with 17 individuals (CPP-guided group) who were on the CPP-guided treatment aimed at maintaining CPP > 70 mmHg using both optimisations of ICP and mean arterial pressure (MAP). RESULTS MAP, cumulative crystalloid doses and fluid balance were similar in both groups. However, the incidence of delayed cerebral ischaemia was significantly lower in the CPP-guided group (14% vs. 64%, p < 0.01), and functional outcome as assessed by the Glasgow Outcome Scale at 30 days after SAH was improved (29.0% vs. 5.5%, p = 0.03). CONCLUSIONS This preliminary analysis showed that implementing a CPP-guided treatment approach aimed at maintaining a CPP > 70 mmHg may reduce the occurrence of delayed cerebral ischaemia and improve functional outcomes in patients with SAH. This observation merits further prospective investigation of the use of CPP-guided treatment in patients with SAH.
Collapse
Affiliation(s)
- Agata Gradys
- Department of Anaesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Jakub Szrama
- Department of Anaesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Zsolt Molnar
- Department of Anaesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
| | - Przemysław Guzik
- Department of Cardiology, Intensive Therapy, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Kusza
- Department of Anaesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| |
Collapse
|
240
|
Kalasapudi L, Williamson S, Shipper AG, Motta M, Esenwa C, Otite FO, Chaturvedi S, Morris NA. Scoping Review of Racial, Ethnic, and Sex Disparities in the Diagnosis and Management of Hemorrhagic Stroke. Neurology 2023; 101:e267-e276. [PMID: 37202159 PMCID: PMC10382273 DOI: 10.1212/wnl.0000000000207406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/28/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In the United States, Black, Hispanic, and Asian Americans experience excessively high incidence rates of hemorrhagic stroke compared with White Americans. Women experience higher rates of subarachnoid hemorrhage than men. Previous reviews detailing racial, ethnic, and sex disparities in stroke have focused on ischemic stroke. We performed a scoping review of disparities in the diagnosis and management of hemorrhagic stroke in the United States to identify areas of disparities, research gaps, and evidence to inform efforts aimed at health equity. METHODS We included studies published after 2010 that assessed racial and ethnic or sex disparities in the diagnosis or management of patients aged 18 years or older in the United States with a primary diagnosis of spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage. We did not include studies assessing disparities in incidence, risks, or mortality and functional outcomes of hemorrhagic stroke. RESULTS After reviewing 6,161 abstracts and 441 full texts, 59 studies met our inclusion criteria. Four themes emerged. First, few data address disparities in acute hemorrhagic stroke. Second, racial and ethnic disparities in blood pressure control after intracerebral hemorrhage exist and likely contribute to disparities in recurrence rates. Third, racial and ethnic differences in end-of-life care exist, but further work is required to understand whether these differences represent true disparities in care. Fourth, very few studies specifically address sex disparities in hemorrhagic stroke care. DISCUSSION Further efforts are necessary to delineate and correct racial, ethnic, and sex disparities in the diagnosis and management of hemorrhagic stroke.
Collapse
Affiliation(s)
- Lakshman Kalasapudi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Stacey Williamson
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Andrea G Shipper
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Melissa Motta
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Charles Esenwa
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Fadar Oliver Otite
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Seemant Chaturvedi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Nicholas A Morris
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse.
| |
Collapse
|
241
|
Li X, Zeng L, Lu X, Chen K, Yu M, Wang B, Zhao M. Early Brain Injury and Neuroprotective Treatment after Aneurysmal Subarachnoid Hemorrhage: A Literature Review. Brain Sci 2023; 13:1083. [PMID: 37509013 PMCID: PMC10376973 DOI: 10.3390/brainsci13071083] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Early brain injury (EBI) subsequent to subarachnoid hemorrhage (SAH) is strongly associated with delayed cerebral ischemia and poor patient prognosis. Based on investigations into the molecular mechanisms underlying EBI, neurovascular dysfunction resulting from SAH can be attributed to a range of pathological processes, such as microvascular alterations in brain tissue, ionic imbalances, blood-brain barrier disruption, immune-inflammatory responses, oxidative stress, and activation of cell death pathways. Research progress presents a variety of promising therapeutic approaches for the preservation of neurological function following SAH, including calcium channel antagonists, endothelin-1 receptor blockers, antiplatelet agents, anti-inflammatory agents, and anti-oxidative stress agents. EBI can be mitigated following SAH through neuroprotective measures. To enhance our comprehension of the relevant molecular pathways involved in brain injury, including brain ischemia-hypoxic injury, neuroimmune inflammation activation, and the activation of various cell-signaling pathways, following SAH, it is essential to investigate the evolution of these multifaceted pathophysiological processes. Facilitating neural repair following a brain injury is critical for improving patient survival rates and quality of life.
Collapse
Affiliation(s)
- Xiaopeng Li
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Lang Zeng
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xuanzhen Lu
- Department of Neurology, The Third Hospital of Wuhan, Wuhan 430073, China
| | - Kun Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Maling Yu
- Department of Neurology, The Third Hospital of Wuhan, Wuhan 430073, China
| | - Baofeng Wang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Min Zhao
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| |
Collapse
|
242
|
Liu J, Wang S, Ji L, Wang X, Zhao H. Association between baseline pulse pressure and hospital mortality in non-traumatic subarachnoid hemorrhage patients: a retrospective cohort study. Front Neurol 2023; 14:1176546. [PMID: 37528860 PMCID: PMC10389704 DOI: 10.3389/fneur.2023.1176546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/27/2023] [Indexed: 08/03/2023] Open
Abstract
Background and purpose Previous studies have described an association between pulse pressure (PP) level and mortality in stroke patients. Evidence of associations between PP level and the risk of mortality remains unknown in non-traumatic subarachnoid hemorrhage (SAH) patients. We aimed to explore the relationship between the baseline PP level and hospital mortality. Methods This cohort study of 693 non-traumatic SAH adults used Medical Information Mart for Intensive Care (MIMIC-IV) data from 2008-2019 admissions to Intensive Care Unit (ICU). PP level was calculated as the first value after admission to the ICU. The endpoint of the study was in-hospital mortality. Cox proportional hazards models were utilized to analyze the association between baseline PP level and hospital mortality. Restricted Cubic Splines (RCS) analysis was utilized to determine the relationship curve between hospital mortality and PP level and examine the threshold saturation effect. We further applied Kaplan-Meier survival curve analysis to examine the consistency of these correlations. The interaction test was used to identify subgroups with differences. Results The mean age of the study population was 58.8 ± 14.6 years, and 304 (43.9%) of participants were female. When baseline PP level was assessed in quartiles, compared to the reference group (Q1 ≤ 56 mmHg), the adjusted hazard ratio (HR) in Q2 (57-68 mmHg), Q3(69-82 mmHg), Q4 (≥83 mmHg) were 0.55 (95% CI: 0.33-0.93, p = 0.026), 0.99 (95% CI, 0.62-1.59, p = 0.966), and 0.99 (95% CI: 0.62-1.59, p = 0.954), respectively. In the threshold analysis, for every 5 mmHg increase in PP level, there was an 18.2% decrease in hospital mortality (adjusted HR, 0.818; 95% CI, 0.738-0.907; p = 0.0001) in those with PP level less than 60 mmHg, and a 7.7% increase in hospital mortality (adjusted HR, 1.077; 95% CI, 1.018-1.139; p = 0.0096) in those with PP level was 60 mmHg or higher. Conclusion For patients with non-traumatic SAH, the association between baseline PP and risk of hospital mortality was non-linear, with an inflection point at 60 mmHg and a minimal risk at 57 to 68 mmHg (Q2) of baseline PP level.
Collapse
Affiliation(s)
- Jiuling Liu
- Department of Neurology, Nanjing BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Shu Wang
- Department of Anesthesiology, The Yancheng School of Clinical Medicine of Nanjing Medical University (Yancheng Third People's Hospital), Yancheng, Jiangsu Province, China
| | - Lin Ji
- Department of Anesthesiology, The Yancheng School of Clinical Medicine of Nanjing Medical University (Yancheng Third People's Hospital), Yancheng, Jiangsu Province, China
| | - Xiaoqing Wang
- Department of Anaesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hang Zhao
- Department of Anesthesiology, The Yancheng School of Clinical Medicine of Nanjing Medical University (Yancheng Third People's Hospital), Yancheng, Jiangsu Province, China
| |
Collapse
|
243
|
Kim KH, Lee BJ, Koo HW. Effect of Cilostazol on Delayed Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage Using Explainable Predictive Modeling. Bioengineering (Basel) 2023; 10:797. [PMID: 37508824 PMCID: PMC10376257 DOI: 10.3390/bioengineering10070797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/30/2023] Open
Abstract
The studies interpreting DCI, a complication of SAH, and identifying correlations are very limited. This study aimed to investigate the effect of cilostazol on ACV and DCI after coil embolization for ruptured aneurysms (n = 432). A multivariate analysis was performed and explainable artificial intelligence approaches were used to analyze the contribution of cilostazol as a risk factor on the development of ACV and DCI with respect to global and local interpretation. The cilonimo group was significantly lower than the nimo group in ACV (13.5% vs. 29.3; p = 0.003) and DCI (7.9% vs. 20.7%; p = 0.006), respectively. In a multivariate logistic regression, the odds ratio for DCI for the cilonimo group, female sex, and aneurysm size was 0.556 (95% confidence interval (CI), 0.351-0.879; p = 0.012), 3.713 (95% CI, 1.683-8.191; p = 0.001), and 1.106 (95% CI, 1.008-1.214; p = 0.034). The risk of a DCI occurrence was significantly increased with an aneurysm size greater than 10 mm (max 80%). The mean AUC of the XGBoost and logistic regression models was 0.94 ± 0.03 and 0.95 ± 0.04, respectively. Cilostazol treatment combined with nimodipine could decrease the prevalence of ACV (13.5%) and DCI (7.9%) in patients with aSAH.
Collapse
Affiliation(s)
- Kwang Hyeon Kim
- Department of Neurosurgery, College of Medicine, Inje University Ilsan Paik Hospital, Goyang 10380, Republic of Korea
| | - Byung-Jou Lee
- Department of Neurosurgery, College of Medicine, Inje University Ilsan Paik Hospital, Goyang 10380, Republic of Korea
| | - Hae-Won Koo
- Department of Neurosurgery, College of Medicine, Inje University Ilsan Paik Hospital, Goyang 10380, Republic of Korea
| |
Collapse
|
244
|
Zhong S, Liu T, Zhai Q, Zhang X, Jing H, Li K, Liu S, Liu G, Wang L, Li L, Tao S, Ren L, Shi X, Bao Y. Impacts of Statin Therapy Strategies on Incidence of Ischemic Cerebrovascular Events in Patients With Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Bayesian Network Meta-Analysis. Neurosurgery 2023; 93:24-32. [PMID: 36794961 DOI: 10.1227/neu.0000000000002392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 12/06/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The exacerbation of neurological outcomes often occurs in aneurysmal subarachnoid hemorrhage (aSAH). Statins have been commonly used for aSAH; however, there is lack of evidence of the pharmacological efficacy of different dosages and types of statins. OBJECTIVE To apply the Bayesian network meta-analysis to analyze the optimal dosage and type of statins for the amelioration of ischemic cerebrovascular events (ICEs) in patients with aSAH. METHODS We developed the Bayesian network meta-analysis and systemic review to analyze the effects of statins on functional prognosis and the impacts of optimal dosage and type of statins on ICEs in patients with aSAH. The outcome variables of the analysis were the incidence of ICEs and functional prognosis. RESULTS A total of 2569 patients with aSAH across 14 studies were included. Analysis of 6 randomized controlled trials showed that statin use significantly improved functional prognosis in patients with aSAH (risk ratio [RR], 0.73; 95% CI, 0.55-0.97). Statins significantly reduced the incidence of ICEs (RR, 0.78; 95% CI, 0.67-0.90). Pravastatin (40 mg/d) decreased the incidence ICEs compared with placebo (RR, 0.14; 95% CI, 0.03-0.65) and was ranked the most effective, presenting with a significantly lower rate of the incidence ICEs than the worst-ranked simvastatin (40 mg/d) (RR, 0.13; 95% CI, 0.02-0.79). CONCLUSION Statins could significantly diminish the incidence of ICEs and enhance functional prognosis in patients with aSAH. Various types and dosages of statins show distinct efficacies.
Collapse
Affiliation(s)
- Shiyu Zhong
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Qingqing Zhai
- School of Management, Shanghai University, Shanghai, China
| | - Xudong Zhang
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Huiquan Jing
- School of Public Health, Capital Medical University, Beijing, China
| | - Kunhang Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shengyu Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Guojun Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Liang Wang
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Lishuai Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shanwei Tao
- Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, China
| | - Lijie Ren
- Neurology Department of Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Futian, Shenzhen, China
| | - Xin Shi
- School of Maths and Information Science, Shandong University of Technology and Business, Yantai, Shandong, China
- Business School, All Saints Campus, Manchester Metropolitan University, Manchester, United Kingdom
| | - Yijun Bao
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| |
Collapse
|
245
|
Palmisciano P, Hoz SS, Johnson MD, Forbes JA, Prestigiacomo CJ, Zuccarello M, Andaluz N. External Validation of an Extreme Gradient Boosting Model for Prediction of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 175:e108-e114. [PMID: 36914029 DOI: 10.1016/j.wneu.2023.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) may significantly worsen the functional status of patients with aneurysmal subarachnoid hemorrhage (aSAH). Several authors have designed predictive models for early identification of patients at risk of post-aSAH DCI. In this study, we externally validate an extreme gradient boosting (EGB) forecasting model for post-aSAH DCI prediction. METHODS A 9-year institutional retrospective review of patients with aSAH was performed. Patients were included if they underwent surgical or endovascular treatment and had available follow-up data. DCI was diagnosed as new-onset neurologic deficits at 4-12 days after aneurysm rupture, defined as worsening Glasgow Coma Scale score for ≥2 points, and new ischemic infarcts at imaging. RESULTS We collected 267 patients with aSAH. At admission, median Hunt-Hess score was 2 (range, 1-5), median Fisher score 3 (range, 1-4), and median modified Fisher score 3 (range, 1-4). One-hundred and forty-five patients underwent external ventricular drainage placement for hydrocephalus (54.3%). The ruptured aneurysms were treated with clipping (64%), coiling (34.8%), and stent-assisted coiling (1.1%). Fifty-eight patients (21.7%) were diagnosed with clinical DCI and 82 (30.7%) with asymptomatic imaging vasospasm. The EGB classifier correctly predicted 19 cases of DCI (7.1%) and 154 cases of no-DCI (57.7%), achieving sensitivity of 32.76% and specificity of 73.68%. The calculated F1 score and accuracy were 0.288% and 64.8%, respectively. CONCLUSIONS We validated that the EGB model is a potential assistant tool to predict post-aSAH DCI in clinical practice, finding moderate-high specificity but low sensitivity. Future research should investigate the underlying pathophysiology of DCI to allow the development of high-performing forecasting models.
Collapse
Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Samer S Hoz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mark D Johnson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| |
Collapse
|
246
|
Fatima K, Ur Rehman MA, Asmar A, Farooq H, Ahmad NUS, Danial A, Ur Rehman ME, Khan AA, Tahir S, Ahmed U, Zubair S, Khawaja A. The efficacy of antifibrinolytic therapy in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Future Sci OA 2023; 9:FSO866. [PMID: 37228855 PMCID: PMC10203907 DOI: 10.2144/fsoa-2023-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023] Open
Abstract
Aim The efficacy of antifibrinolytics in subarachnoid hemorrhage remains unclear due to conflicting evidence from studies. Materials & methods Online databases were queried to include randomized controlled trials and propensity matched observational studies. We used Review Manager for the statistical analysis, presenting results as odds ratios with 95% CI. Results The 12 shortlisted studies included 3359 patients, of which 1550 (46%) were in the intervention (tranexamic acid) group and 1809 (54%) in the control group. Antifibrinolytic therapy significantly reduced the risk of rebleeding (OR: 0.55; 95% CI: 0.40-0.75; p = 0.0002) with no significant decrease in poor clinical outcome (OR: 1.02; 95% CI: 0.86-1.20; p = 0.85) and all-cause mortality (OR: 0.92; CI: 0.72-1.17; p = 0.50). Conclusion In patients with subarachnoid hemorrhage, antifibrinolytics reduce the risk of rebleeding without significantly affecting mortality or clinical outcomes.
Collapse
Affiliation(s)
- Kaneez Fatima
- Dow University of Health Sciences, Mission Rd, New Labour Colony Nanakwara, Karachi, Sindh, 74200, Pakistan
| | | | - Abyaz Asmar
- Mayo Hospital, King Edward Medical University, Neela Gumbad Chowk Anarkali, Lahore, 54000, Pakistan
| | - Hareem Farooq
- Mayo Hospital, King Edward Medical University, Neela Gumbad Chowk Anarkali, Lahore, 54000, Pakistan
| | - Noor-Us-Sabah Ahmad
- Mayo Hospital, King Edward Medical University, Neela Gumbad Chowk Anarkali, Lahore, 54000, Pakistan
| | - Ahmad Danial
- Quaid-e-Azam Medical College, Bahawalpur, 63100, Pakistan
| | | | - Abdullah Ali Khan
- Mayo Hospital, King Edward Medical University, Neela Gumbad Chowk Anarkali, Lahore, 54000, Pakistan
| | - Sidra Tahir
- Mayo Hospital, King Edward Medical University, Neela Gumbad Chowk Anarkali, Lahore, 54000, Pakistan
| | - Umair Ahmed
- Mayo Hospital, King Edward Medical University, Neela Gumbad Chowk Anarkali, Lahore, 54000, Pakistan
| | - Salman Zubair
- St Anthony Hospital, 1000 N Lee Ave, Oklahoma City, OK 73102, USA
| | - Ayaz Khawaja
- Wayne State University, 540 E Canfield St, Detroit, MI 48201, USA
| |
Collapse
|
247
|
Meyer A, Forman E, Moody S, Stretz C, Potter NS, Subramaniam T, Top I, Wendell LC, Thompson BB, Reznik ME, Furie KL, Mahta A. Cisternal Score: A Radiographic Score to Predict Ventriculoperitoneal Shunt Requirement in Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2023; 93:75-83. [PMID: 36695607 DOI: 10.1227/neu.0000000000002374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/24/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Persistent hydrocephalus requiring a ventriculoperitoneal shunt (VPS) can complicate the management of aneurysmal subarachnoid hemorrhage (aSAH). Identification of high-risk patients may guide external ventricular drain management. OBJECTIVE To identify early radiographic predictors for persistent hydrocephalus requiring VPS placement. METHODS In a 2-center retrospective study, we compared radiographic features on admission noncontrast head computed tomography scans of patients with aSAH requiring a VPS to those who did not, at 2 referral academic centers from 2016 through 2021. We quantified blood clot thickness in the basal cisterns including interpeduncular, ambient, crural, prepontine, interhemispheric cisterns, and bilateral Sylvian fissures. We then created the cisternal score (CISCO) using features that were significantly different between groups. RESULTS We included 229 survivors (mean age 55.6 years [SD 13.1]; 63% female) of whom 50 (22%) required VPS. CISCO was greater in patients who required a VPS than those who did not (median 4, IQR 3-6 vs 2, IQR 1-4; P < .001). Higher CISCO was associated with higher odds of developing persistent hydrocephalus with VPS requirement (odds ratio 1.6 per point increase, 95% CI 1.34-1.9; P < .001), independent of age, Hunt and Hess grades, and modified GRAEB scores. CISCO had higher accuracy in predicting VPS requirement (area under the curve 0.75, 95% CI 0.68-0.82) compared with other predictors present on admission. CONCLUSION Cisternal blood clot quantification on admission noncontrast head computed tomography scan is feasible and can be used in predicting persistent hydrocephalus with VPS requirement in patients with aSAH. Future prospective studies are recommended to further validate this tool.
Collapse
Affiliation(s)
- Aiden Meyer
- Brown University, Providence, Rhode Island, USA
| | | | - Scott Moody
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - Christoph Stretz
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nicholas S Potter
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Thanujaa Subramaniam
- Divisions of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ilayda Top
- Divisions of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Linda C Wendell
- Division of Neurology, Mount Auburn Hospital, Cambridge, Massachusetts, USA
| | - Bradford B Thompson
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Michael E Reznik
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ali Mahta
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
248
|
Foudhaili A, Barthélémy R, Collet M, de Roquetaillade C, Kerever S, Vitiello D, Mebazaa A, Chousterman BG. Impact of Early Out-of-Bed Mobilization on Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study. World Neurosurg 2023; 175:e278-e287. [PMID: 36966907 DOI: 10.1016/j.wneu.2023.03.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Effects of early mobilization are not well documented in patients with aneurysmal subarachnoid hemorrhage (aSAH). Only a few studies have investigated it through progressive mobilization protocols and suggested that it is safe and feasible. This study aimed to determine the impact of early out-of-bed mobilization (EOM) on 3-month functional outcome and cerebral vasospasm (CVS) occurrence in patients with aSAH. METHODS A retrospective review of consecutive patients admitted to the intensive care unit with a diagnosis of aSAH was performed. EOM was defined as out-of-bed (OOB) mobilization performed before or on day 4 after aSAH onset. The primary outcome was 3-month functional independence (i.e., a modified Rankin Scale below 3) and the occurrence of CVS. RESULTS A total of 179 patients with aSAH met the inclusion criteria. Thirty-one patients constituted the EOM group, and 148 patients were in the delayed out-of-bed mobilization group. Functional independence was more frequent in the EOM group than in the delayed out-of-bed mobilization group (n = 26 [84%] vs. n = 83 [56%], P = 0.004). In a multivariable analysis, EOM was an independent predictor of functional independence (adjusted odds ratio = 3.11; 95% confidence interval, 1.11-10.36; P < 0.05). The delay between bleeding and first OOB mobilization was also identified as an independent risk factor for the occurrence of CVS (adjusted odds ratio = 1.12; 95% confidence interval = 1.06-1.18, P < 0.001). CONCLUSIONS EOM was independently associated with favorable functional outcome after aSAH. The delay between bleeding and OOB mobilization was an independent risk factor for reduced functional independence and CVS occurrence. Prospective randomized trials are necessary to confirm these results and improve clinical practice.
Collapse
Affiliation(s)
- Adéla Foudhaili
- Université Paris Cité, Inserm, MASCOT, Paris, France; Department of Physical Medicine and Rehabilitation, CHU Lariboisière, AP-HP, Paris, France; Université Paris Cité, Institut des Sciences du Sport-Santé de Paris, Paris, France.
| | - Romain Barthélémy
- Université Paris Cité, Inserm, MASCOT, Paris, France; Department of Anesthesiology and Critical Care, CHU Lariboisière, AP-HP, Paris, France
| | - Magalie Collet
- Université Paris Cité, Inserm, MASCOT, Paris, France; Department of Anesthesiology and Critical Care, CHU Lariboisière, AP-HP, Paris, France
| | - Charles de Roquetaillade
- Université Paris Cité, Inserm, MASCOT, Paris, France; Department of Anesthesiology and Critical Care, CHU Lariboisière, AP-HP, Paris, France
| | - Sébastien Kerever
- Department of Anesthesiology and Critical Care, CHU Lariboisière, AP-HP, Paris, France; Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Centre de Recherche Epidémiologie et StatistiqueS, Paris, France
| | - Damien Vitiello
- Université Paris Cité, Institut des Sciences du Sport-Santé de Paris, Paris, France
| | - Alexandre Mebazaa
- Université Paris Cité, Inserm, MASCOT, Paris, France; Department of Anesthesiology and Critical Care, CHU Lariboisière, AP-HP, Paris, France
| | - Benjamin G Chousterman
- Université Paris Cité, Inserm, MASCOT, Paris, France; Department of Anesthesiology and Critical Care, CHU Lariboisière, AP-HP, Paris, France
| |
Collapse
|
249
|
Yuwapattanawong K, Chanthima P, Thamjamrassri T, Keen J, Qiu Q, Fong C, Robinson EF, Dhulipala VB, Walters AM, Athiraman U, Kim LJ, Vavilala MS, Levitt MR, Lele AV. The Association Between Illness Severity Scores and In-hospital Mortality After Aneurysmal Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2023; 35:299-306. [PMID: 35297396 DOI: 10.1097/ana.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose of this study was to examine the association with in-hospital mortality of 8 illness severity scores in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS In a retrospective cohort study, we investigated the association with in-hospital mortality of admission Hunt and Hess (HH) score, Fisher grade, severity of illness and risk of mortality scores, and serial Glasgow coma scale (GCS) score in patients with aSAH. We also explored the changes in GCS between admission and discharge using a multivariate model adjusting for age, clinical vasospasm, and external ventricular drain status. RESULTS Data from 480 patients with aSAH, of which 383 (79.8%) aneurysms were in the anterior circulation, were included in analysis. Patients were female (n=340, 70.8%) with a median age of 56 (interquartile range: 48 to 66) years. The majority (n=332, 69.2%) had admission HH score 3 to 5, Fisher grade 3 to 4 (n=437, 91%), median severity of illness 3 (range: 1 to 4), median risk of mortality 3 (range: 1 to 4), and median admission GCS of 13 (interquartile range: 7 to 15). Overall, 406 (84.6%) patients received an external ventricular drain, 469 (97.7%) underwent aneurysm repair, and 60 died (12.5%). Compared with admission HH score, GCS 24 hours after admission (area under the curve: 0.84, 95% confidence interval [CI]: 0.79-0.88) and 24 hours after aneurysm repair (area under the curve: 0.87, 95% CI: 0.82-0.90) were more likely to be associated with in-hospital mortality. Among those who died, the greatest decline in GCS was noted between 24 hours after aneurysm repair and discharge (-3.38 points, 95% CI: -4.17, -2.58). CONCLUSIONS Compared with admission HH score, GCS 24 hours after admission (or 24 h after aneurysm repair) is more likely to be associated with in-hospital mortality after aSAH.
Collapse
Affiliation(s)
| | | | | | | | - Qian Qiu
- Harborview Injury Prevention and Research Center
| | - Christine Fong
- Anesthesiology and Pain Medicine, Harborview Medical Center
| | | | | | | | | | | | - Monica S Vavilala
- Harborview Injury Prevention and Research Center
- Anesthesiology and Pain Medicine, Harborview Medical Center
| | | | - Abhijit V Lele
- Harborview Injury Prevention and Research Center
- Departments of Neurological Surgery
- Anesthesiology and Pain Medicine, Harborview Medical Center
- Neurocritical Service, Harborview Medical Center, Seattle, WA
| |
Collapse
|
250
|
Alkhachroum A, Zhou L, Asdaghi N, Gardener H, Ying H, Gutierrez CM, Manolovitz BM, Samano D, Bass D, Foster D, Sur NB, Rose DZ, Jameson A, Massad N, Kottapally M, Merenda A, Starke RM, O'Phelan K, Romano JG, Claassen J, Sacco RL, Rundek T. Predictors and Temporal Trends of Withdrawal of Life-Sustaining Therapy After Acute Stroke in the Florida Stroke Registry. Crit Care Explor 2023; 5:e0934. [PMID: 37378082 PMCID: PMC10292735 DOI: 10.1097/cce.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
Temporal trends and factors associated with the withdrawal of life-sustaining therapy (WLST) after acute stroke are not well determined. DESIGN Observational study (2008-2021). SETTING Florida Stroke Registry (152 hospitals). PATIENTS Acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Importance plots were performed to generate the most predictive factors of WLST. Area under the curve (AUC) for the receiver operating curve were generated for the performance of logistic regression (LR) and random forest (RF) models. Regression analysis was applied to evaluate temporal trends. Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST. Patients who had WLST were older (77 vs 70 yr), more women (57% vs 49%), White (76% vs 67%), with greater stroke severity on the National Institutes of Health Stroke Scale greater than or equal to 5 (29% vs 19%), more likely hospitalized in comprehensive stroke centers (52% vs 44%), had Medicare insurance (53% vs 44%), and more likely to have impaired level of consciousness (38% vs 12%). Most predictors associated with the decision to WLST in AIS were age, stroke severity, region, insurance status, center type, race, and level of consciousness (RF AUC of 0.93 and LR AUC of 0.85). Predictors in ICH included age, impaired level of consciousness, region, race, insurance status, center type, and prestroke ambulation status (RF AUC of 0.76 and LR AUC of 0.71). Factors in SAH included age, impaired level of consciousness, region, insurance status, race, and stroke center type (RF AUC of 0.82 and LR AUC of 0.72). Despite a decrease in the rates of early WLST (< 2 d) and mortality, the overall rates of WLST remained stable. CONCLUSIONS In acute hospitalized stroke patients in Florida, factors other than brain injury alone contribute to the decision to WLST. Potential predictors not measured in this study include education, culture, faith and beliefs, and patient/family and physician preferences. The overall rates of WLST have not changed in the last 2 decades.
Collapse
Affiliation(s)
| | - Lili Zhou
- Department of Neurology, University of Miami, Miami, FL
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, FL
| | | | - Hao Ying
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Daniel Samano
- Department of Neurology, University of Miami, Miami, FL
| | - Danielle Bass
- Department of Neurology, University of Miami, Miami, FL
| | - Dianne Foster
- Regional Director Quality Improvement, American Heart Association, Dallas, TX
| | - Nicole B Sur
- Department of Neurology, University of Miami, Miami, FL
| | - David Z Rose
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Angus Jameson
- Department of Emergency Medicine, Pinellas County Emergency Medical Services, Largo, FL
| | - Nina Massad
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | - Jose G Romano
- Department of Neurology, University of Miami, Miami, FL
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miami, FL
| | | |
Collapse
|