Mild exercise reduces cerebral vasospasm after aneurysm subarachnoid hemorrhage: a retrospective clinical study and correlation with laboratory investigation

Conditioning-based therapeutics for aneurysmal subarachnoid hemorrhage - A critical review

Aneurysmal subarachnoid hemorrhage (SAH) carries significant mortality and morbidity, with nearly half of SAH survivors having major cognitive dysfunction that impairs their functional status, emotional health, and quality of life. Apart from the initial hemorrhage severity, secondary brain injury due to early brain injury and delayed cerebral ischemia plays a leading role in patient outcome after SAH. While many strategies to combat secondary brain injury have been developed in preclinical studies and tested in late phase clinical trials, only one (nimodipine) has proven efficacious for improving long-term functional outcome. The causes of these failures are likely multitude, but include use of therapies targeting only one element of what has proven to be multifactorial brain injury process. Conditioning is a therapeutic strategy that leverages endogenous protective mechanisms to exert powerful and remarkably pleiotropic protective effects against injury to all major cell types of the CNS. The aim of this article is to review the current body of evidence for the use of conditioning agents in SAH, summarize the underlying neuroprotective mechanisms, and identify gaps in the current literature to guide future investigation with the long-term goal of identifying a conditioning-based therapeutic that significantly improves functional and cognitive outcomes for SAH patients.

Early mobilization of patients with subarachnoid haemorrhage: a national survey of french intensive care units

OBJECTIVE

To describe French intensive care unit practices regarding the mobilization of patients with subarachnoid haemorrhage.

DESIGN

A cross-sectional nationwide survey study.

SUBJECTS

Intensivists and physiotherapists or nurses from French intensive care units managing patients with subarachnoid haemorrhage.

METHODS

An online questionnaire survey was distributed through the Neurocritical Care and Neuro Anesthesiology French Speaking Society.

RESULTS

The response rate was 89%. Of these, 90% did not have a mobilization protocol for patients with subarachnoid haemorrhage. Sixteen percent of departments prohibited all forms of motor physiotherapy for a predefined period. Nineteen percent systematically prohibited out-of-bed mobilization, regardless of the severity of subarachnoid haemorrhage and in the absence of any complication, for a predefined period. The main factors that would delay or interrupt physiotherapy prescription were intracranial hypertension (79%), currently treated vasospasm (59%), and suspicion of vasospasm (44%). Ninety-one percent of the centres identified at least one complication that could be associated with standing upright. These mainly included decreased cerebral perfusion (71%), dislodged external ventricular or lumbar derivations (68%), and haemodynamic instability (65%).

CONCLUSION

Mobilization of patients with subarachnoid haemorrhage is heterogeneous among French neuro-intensive care units and several barriers preclude improvement of mobilization practices. Interventional studies assessing mobilization practices, as well as education and training of staff, are crucial to ensure the proper management of patients with subarachnoid haemorrhage and to improve outcomes.

Early versus delayed mobilization after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of efficacy and safety

OBJECTIVE

A central tenet of Enhanced Recovery After Surgery (ERAS) is evidence-based medicine. Survivors of aneurysmal subarachnoid hemorrhage (aSAH) constitute a fragile patient population prone to prolonged hospitalization within neurointensive care units (NICUs), prolonged immobilization, and a range of nosocomial adverse events. Potentially, well-monitored early mobilization (EM) could constitute a beneficial element of ERAS protocols in this population. Therefore, the objective was to summarize the available evidence on EM strategies in patients with aSAH.

METHODS

The authors retrieved prospective and retrospective studies that reported efficacy or safety data on EM (defined as EM in the NICU starting ≤ 7 days after ictus) versus delayed mobilization (DM) (any strategy that comparatively delayed mobilization) after aSAH and were published after January 1, 2000, in PubMed/MEDLINE, Embase, and the Cochrane Library. Random-effects meta-analysis was performed.

RESULTS

Ten studies analyzing 1292 patients were included for quantitative synthesis, including 1 randomized, 1 prospective nonrandomized, and 8 retrospective studies. Modified Rankin Scale scores at discharge were not different between the EM and DM groups (mean difference [MD] [95% CI] -0.86 [-2.93 to 1.20] points, p = 0.41). Hospital length of stay in days was markedly reduced in the EM group (MD [95% CI] -6.56 [-10.64 to -2.47] days, p = 0.002). Although there was a statistically significant reduction in radiological vasospasms (OR [95% CI] 0.65 [0.44-0.97], p = 0.03), the reduction in clinically relevant vasospasms was nonsignificant (OR [95% CI] 0.63 [0.31-1.26], p = 0.19). The odds of shunting were significantly lower in the EM group (OR [95% CI] 0.61 [0.39-0.95], p = 0.03). The rates of mortality, pneumonia, and thrombosis were similar among groups (p > 0.05).

CONCLUSIONS

Due to a lack of high-quality studies, vastly varying protocols, and resulting statistical clinical and statistical heterogeneity, the level of evidence for recommendations regarding EM in patients with aSAH remains low. The currently available data indicated that mobilization within the first 5 days after aneurysm repair was feasible and safe without significant excessive adverse events, that neurological outcome with EM was almost certainly not worse than with prolonged immobilization, and that there was likely at least some reduction in length of hospital stay. Radiological and clinical vasospasms were not more frequent-with signals even trending toward a decrease-in patients who mobilized early. Higher-quality studies and implementation of full ERAS protocols are necessary to evaluate efficacy and safety with a higher level of evidence and to guide practical implementation through increased standardization. Clinical trial registration no.: CRD42023432828 (www.crd.york.ac.uk/prospero).

Initiating Mobilization Is Not Associated with Symptomatic Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Multicenter Case-control Study

OBJECTIVE

The study aim was to investigate the association between initiating mobilization within 7 days after onset and symptomatic cerebral vasospasm (SCV) in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

This was a retrospective multicenter case-control study in Japan. Patients with a diagnosis of aSAH who underwent physical therapy with/without occupational therapy were included and categorized into 2 groups according to the presence or absence of SCV. Initiating mobilization was defined as sitting on the bed edge (at least once, with/without assist, regardless of duration) within 7 days after aSAH onset. Cox proportional hazards regression analysis was performed to evaluate the association between initiating mobilization within 7 days after onset and SCV.

RESULTS

The analysis included 510 patients. Among all included patients, 57 (11.2%) patients had SCV. In the univariate Cox proportional hazards regression analysis, initiating of mobilization was not associated with SCV (hazard ratio [HR] = 0.78; 95% confidence interval [CI] = 0.45-1.32). In the multivariate analysis, only the modified Fisher scale was significantly associated with SCV (HR = 26.23; 95% CI = 1.21-571.0).

CONCLUSION

Initiating mobilization within 7 days after aSAH onset was not associated with SCV in patients with aSAH.