Update on subarachnoid haemorrhage

Optimal Course of Statins for Patients With Aneurysmal Subarachnoid Hemorrhage: Is Longer Treatment Better? A Meta-Analysis of Randomized Controlled Trials

Statins are used in clinical practice to prevent from complications such as cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH). However, the efficacy and safety of statins are still controversial due to insufficient evidence from randomized controlled trials and inconsistent results of the existing studies. This meta-analysis aimed to systematically review the latest evidence on the time window and complications of statins in aSAH. The randomized controlled trials in the databases of The Cochrane Library, PubMed, Web of Science, Embase, CNKI, and Wanfang from January 2005 to April 2021 were searched and analyzed systematically. Data analysis was performed using Stata version 16.0. The fixed-effects model (M-H method) with effect size risk ratio (RR) was used for subgroups with homogeneity, and the random-effects model (D-L method) with effect size odds ratio (OR) was used for subgroups with heterogeneity. The primary outcomes were poor neurological prognosis and all-cause mortality, and the secondary outcomes were cerebral vasospasm (CVS) and statin-related complications. This study was registered with PROSPERO (International Prospective Register of Systematic Reviews; CRD42021247376). Nine studies comprising 1,464 patients were included. The Jadad score of the patients was 5–7. Meta-analysis showed that poor neurological prognosis was reduced in patients who took oral statins for 14 days (RR, 0.73 [0.55–0.97]; I² = 0%). Surprisingly, the continuous use of statins for 21 days had no significant effect on neurological prognosis (RR, 1.04 [0.89–1.23]; I² = 17%). Statins reduced CVS (OR, 0.51 [0.36–0.71]; I² = 0%) but increased bacteremia (OR, 1.38 [1.01–1.89]; I² = 0%). In conclusion, a short treatment course of statins over 2 weeks may improve neurological prognosis. Statins were associated with reduced CVS. Based on the pathophysiological characteristics of CVS and the evaluation of prognosis, 2 weeks could be the optimal time window for statin treatment in aSAH, although bacteremia may increase.

PD-1+ Monocytes Mediate Cerebral Vasospasm Following Subarachnoid Hemorrhage

BACKGROUND

Cerebral vasospasm is a major source of morbidity and mortality following aneurysm rupture and has limited treatment options.

OBJECTIVE

To evaluate the role of programmed death-1 (PD-1) in cerebral vasospasm.

METHODS

Endovascular internal carotid artery perforation (ICAp) was used to induce cerebral vasospasm in mice. To evaluate the therapeutic potential of targeting PD-1, programmed death ligand-1 (PD-L1) was administered 1 h after ICAp and vasospasm was measured histologically at the level of the ICA bifurcation bilaterally. PD-1 expressing immune cell populations were evaluated by flow cytometry. To correlate these findings to patients and evaluate the potential of PD-1 as a biomarker, monocytes were isolated from the peripheral blood and analyzed by flow cytometry in a cohort of patients with ruptured cerebral aneurysms. The daily frequency of PD-1+ monocytes in the peripheral blood was correlated to transcranial Doppler velocities as well as clinical and radiographic vasospasm.

RESULTS

We found that PD-L1 administration prevented cerebral vasospasm by inhibiting ingress of activated Ly6c+ and CCR2+ monocytes into the brain. Human correlative studies confirmed the presence of PD-1+ monocytes in the peripheral blood of patients with ruptured aneurysms and the frequency of these cells corresponded with cerebral blood flow velocities and clinical vasospasm.

CONCLUSION

Our results identify PD-1+ monocytes as mediators of cerebral vasospasm and support PD-1 agonism as a novel therapeutic strategy.

Subacute phase of subarachnoid haemorrhage in female rats: Increased intracranial pressure, vascular changes and impaired sensorimotor function

OBJECTIVE

Early brain injury (EBI) and delayed cerebral ischemia (DCI) after subarachnoid haemorrhage (SAH) has devastating consequences but therapeutic options and the underlying pathogenesis remain poorly understood despite extensive preclinical and clinical research. One of the drawbacks of most preclinical studies to date is that the mechanisms behind DCI after SAH are studied only in male animals. In this study we therefore established a female rat model of SAH in order to determine subacute pathophysiological changes that may contribute to DCI in females.

METHODS

Experimental SAH was induced in female rats by intracisternal injection of 300 μL of autologous blood. Sham operation served as a control. Neurological deficits and intracranial pressure measurements were evaluated at both 1 and 2 days after surgery. Additionally, changes in cerebral vascular contractility were evaluated 2 days after surgery using wire myography.

RESULTS

SAH in female rats resulted in sensorimotor deficits and decreased general wellbeing on both day 1 and day 2 after SAH. Intracranial pressure uniformly increased in all rats subjected to SAH on day 1. On day 2 the intracranial pressure had increased further, decreased slightly or remained at the level seen on day 1. Furthermore, female rats subjected to SAH developed cortical brain edema. Cerebral arteries, isolated 2 days after SAH, exhibited increased vascular contractions to endothelin-1 and 5-carboxamidotryptamine.

CONCLUSION

In the subacute phase after SAH in female rats, we observed increased intracranial pressure, decreased wellbeing, sensorimotor deficits, increased vascular contractility and cortical brain edema. Collectively, these pathophysiological changes may contribute to DCI after SAH in females. Previous studies reported similar pathophysiological changes for male rats in the subacute phase after SAH. Thus, prevention of these gender-independent mechanisms may provide the basis for a universal treatment strategy for DCI after SAH. Nevertheless, preclinical studies of potential therapies should employ both male and female SAH models.

Two Similar Cases of a Misdiagnosed Anterior Communicating Aneurysm Rupture

The misdiagnosis of a ruptured aneurysm directly endangers patient's life and health due to the high risk of rebleeding and its sequelae. In this paper, we present two uncommon cases of anterior communicating artery aneurysm rupture with a relatively small intracerebral bleeding, seemingly without a diffuse subarachnoid hemorrhage (SAH), and a relatively mild clinical presentation. In these cases, the initial diagnosis failed, leading to missed aneurysmal ruptures. The atypical or mild clinical presentation, and the absence of SAH on computed tomography (CT) and/or magnetic resonance imaging (MRI) scan or absent blood in the cerebrospinal fluid (CSF) are all factors which could lead to a false or delayed diagnosis. Meticulous evaluation of patient's symptoms, CT, MRI scans, and CSF findings are mandatory. The possibility of a small blood clot without a diffuse SAH must be considered.

Trends for in-hospital metrics in the treatment of intracranial aneurysms in Minas Gerais, Brazil

Background: Aneurysmal subarachnoid hemorrhage (ASAH) and unruptured aneurysm (URA) are particularly important because of the high mortality rates, and physical and cognitive impairment, which affect the economically active population. The present work aims at describing the scenario regarding in-hospital indicators related to the following therapeutic approaches: vascular microsurgery (VMS) and endovascular therapy (EVT) in the state of Minas Gerais, Brazil, in order to gather information to construct hypotheses and plan actions. Methods: The study has an ecological design and it is also analytical for the time trends of 2008-2014. Trends for VMS and EVT therapies and mortality are estimated using linear regression, followed by the Prais-Winsten procedure. Data were obtained through Hospital Information System (Sistema de Informações Hospitalares - SIH) of Brazilian Public Health System (Sistema Único de Saúde - SUS). Results: In 2014, 601 procedures were performed, and out of these, 373 (62%) were triggered by SAH and 228 (38%) by URA. The frequency of procedures performed in males and in females results in a ratio of 1:2 for SAH procedures and 1:3 for URA procedures. A heterogeneous distribution of therapeutic approaches was seen among the hospital studied, suggesting a technological preference, which determines the therapeutic approach. Conclusion: Technological bias was observed for aneurysm treatment in Minas Gerais's hospitals. EVT is seen to have a growing trend to detriment of VMS (β₁ = 0.024; p = 0.025), with a stable mortality for both therapeutics in both pathologies (SAH and URA). EVT has been associated with a shorter hospital stay, with higher expenses for both ASAH and URA treatment. EVT showed an inverse correlation with in-hospital fatality for ASAH treatment.

Spinal dural arteriovenous fistula presenting with subarachnoid hemorrhage: A case report

RATIONALE

Subarachnoid hemorrhage (SAH) is a common and serious disease and one of the most important differential diagnoses in the emergency department.

PATIENT CONCERNS

A 39-year-old female patient with a 12 years' history of migraine, presented with a sudden headache combined with motor aphasia. Physical examination suggested probable positive neck resistance. SAH was confirmed by magnetic resonance imaging. In addition, spinal digital subtraction angiography and spinal vascular computed tomography angiography indicated spinal arteriovenous malformation (SAVM).

DIAGNOSES

The final diagnosis was spinal dural arteriovenous fistula presenting with SAH.

INTERVENTIONS

Following diagnosis, appropriate drugs were administered, but the therapeutic effect was poor. Then the patient was then transferred to a superior hospital where she was treated with interventional embolization.

OUTCOMES

Through 2 years of follow-up, intermittent migraine was found in the patient, but the symptoms of occipital pain, nausea, and vomiting did not occur again.

LESSONS

For patients who have been diagnosed with SAH but have no definite cause, we should pay attention to the etiological screening of SAH, and the possibility of the spinal cord SAH should be vigilant. The pain in the chest and back and the signs of spinal cord may be an important breakthrough in patients with spinal cord SAH, and medical history and physical examination are particularly important.

The diagnostic value of complete blood count parameters in patients with subarachnoid hemorrhage

Objectives

Diagnosis of subarachnoid hemorrhage (SAH) in patients presenting with headache is challenging and there has been any biomarker studied for excluding of SAH in those patients. We aim to determine the sensitivity of leukocytosis or left shift to exclude the diagnosis of SAH in ED patients presenting with headache.

Method

Adult patients with headache who received a computed tomography (CT) with the diagnosis of SAH and had a complete blood count (CBC) represent the case group, headache patients with normal CT and had a CBC represent the control group. The white blood cell (WBC) count and percentage of polymorphonuclear cells (PMNs%) taken during admission and within the first 6 and 12 h of admission were recorded.

Results

A hundred ninety seven patients with SAH and 197 patients without SAH were enrolled in to study. Sensitivity, specificity, NPV and PPV of leukocytosis or increase in PMNs% (left shift) in the diagnosis of SAH was 89.8% (84.5-93.5, 95% CI), 46.7% (39.6-53.9, 95% CI), 82.1% (73.5-88.4, 95% CI) and 62.8% (56.8-68.4, 95% CI) respectively on initial emergency department (ED) admission.

Conclusion

CBC should be considered as a noninvasive test for the exclusion of SAH in ED patients with 6 h observation.

Identification of clinical and paraclinical findings predictive for headache occurrence during spontaneous subarachnoid hemorrhage

OBJECTIVES

Headache is recognized as the main but unwarranted symptom of subarachnoid hemorrhage (SAH). There are no enough findings identified as predictive for headache occurrence in SAH. We evaluated the clinical and paraclinical factors predictive for headache occurrence in SAH.

PATIENTS AND METHODS

We retrospectively analyzed medical records of 431 consecutive non traumatic SAH patients (264 females and 167 males), ages from 19 to 91 years, presenting with headache (70.3%) and without headache (29.7%) during period of 11years.

RESULTS

Among all tested parameters, as negative predictors for headache occurrence were recognized: patients' ages (OR 0.97 [95%CI: 0.96-0.99], p=0.025), persistence of coagulation abnormality (OR 0.23 [95%CI: 0.08-0.67], p=0.006), atrial fibrilation (OR 0.23 [95%CI: 0.09-0.59], p=0.002), chronic renal failure (OR 0.26 [95%CI: 0.09-0.76], p=0.014) and more diseases (OR 0.11 [95%CI: 0.04-0.32], p<0.0001), as higher clinical score (OR 0.94 [95%CI: 0.90-0.99], p=0.018) including positive neurological findings (OR 0.34 [95%CI: 0.21-0.55], p<0.001) and loss of consciousness (OR 0.22 [95%CI: 0.12-0.39], p<0.001) at the SAH onset, while the complaint of neck stiffness was identified as its positive predictor (OR 1.93 [95%CI: 1.19-3.10], p=0.007).

CONCLUSIONS

Although diagnosis based solely on clinical presentation is not reliable and speculative, our findings could provide physicians with evidence to consider SAH not only in conditions of its headache occurrence but also in those with headache absence.

NADPH Oxidase: A Potential Target for Treatment of Stroke

Stroke is the third leading cause of death in industrialized nations. Oxidative stress is involved in the pathogenesis of stroke, and excessive generation of reactive oxygen species (ROS) by mitochondria is thought to be the main cause of oxidative stress. NADPH oxidase (NOX) enzymes have recently been identified and studied as important producers of ROS in brain tissues after stroke. Several reports have shown that knockout or deletion of NOX exerts a neuroprotective effect in three major experimental stroke models. Recent studies also confirmed that NOX inhibitors ameliorate brain injury and improve neurological outcome after stroke. However, the physiological and pathophysiological roles of NOX enzymes in the central nervous system (CNS) are not known well. In this review, we provide a comprehensive summary of our current understanding about expression and physiological function of NOX enzymes in the CNS and its pathophysiological roles in the three major types of stroke: ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage.

Intraventricular Injection of Noncellular Cerebrospinal Fluid from Subarachnoid Hemorrhage Patient into Rat Ventricles Leads to Ventricular Enlargement and Periventricular Injury

Early brain injury and hydrocephalus (HCP) are important mediators of poor outcome in subarachnoid hemorrhage (SAH) patients. We aim to understand the development of HCP and subependymal cellular injury after intraventricular injection of noncellular human SAH cerebrospinal fluid (CSF) into rat ventricles. Two-hundred microliters of noncellular CSF from SAH patients or normal controls were injected into the right lateral ventricle of seven adult male Sprague-Dawley rats. Propidium iodide (PI) was simultaneously injected to detect necrotic cellular death. Rats were then sacrificed 24 h after surgery and the brain specimens were cut and stained for heme oxygenase 1 (HO-1), an oxidative stress marker. We found that the ventricular area at the bregma level in the CSF injection group was significantly larger than that in the control group (p < 0.05). The periventricular tissue in the CSF injection group had significantly more necrotic cell death as well as HO-1 expression as compared with the control group (p < 0.05). In conclusion, injection of SAH patients' CSF into the rat ventricle leads to HCP as well as subependymal injury compared with injection of control CSF.

Cerebrovascular disease

With 16.9 million people who suffered a first-ever stroke in 2010 worldwide, stroke is a very common vascular disease. Epidemiologic studies have played an essential role in assessing this burden and in detecting the risk factors for stroke. Primary prevention of these risk factors, primarily hypertension, smoking, diabetes, and atrial fibrillation, has reduced the incidence in high-income countries. However, stroke remains a major cause of death and disability, and therefore research should be continued. Subarachnoid hemorrhages are less prevalent than strokes but have an even higher risk of death. Similar to stroke, epidemiologic studies identified smoking and hypertension as its most important risk factors, together with excessive alcohol intake. Although rare, arterial dissections, CADASIL, arteriovenous malformations, venous sinus thrombosis, moyamoya disease, and vasculitis can lead to serious symptoms. The burden and risk factors of those rare diseases are more challenging to assess. Whenever possible, they should be recognized in a timely manner for their increased risk of stroke, but most often they are diagnosed only at the time of stroke. Some cerebrovascular abnormalities do not result in immediate symptoms. This subclinical cerebrovascular disease includes silent infarcts, white-matter lesions, and microbleeds, and is incidentally found by neuroimaging. These lesions are not innocent, as several epidemiologic studies have associated subclinical cerebrovascular disease with an increased risk of stroke, cognitive decline, dementia, and death.

Correlating Cerebral (18)FDG PET-CT Patterns with Histological Analysis During Early Brain Injury in a Rat Subarachnoid Hemorrhage Model

Early brain injury (EBI) plays a significant role in poor outcomes for subarachnoid hemorrhage (SAH) patients. Further investigations are required to characterize the cellular metabolic and related histological changes that may contribute to EBI following SAH. We investigated the image patterns of 18-fluorodeoxyglucose positron emission tomography-computed tomography ((18)FDG PET-CT) during EBI and correlated histopathological changes utilizing a rat SAH model. SAH was induced in six adult male Sprague-Dawley rats by endovascular perforation, and animals were randomly assigned to receive (18)FDG PET-CT imaging at either 3 or 12 h post-procedure. Mean (18)FDG standard uptake value (SUV) of the brain was calculated. Animals were euthanized 48 h post-procedure, and brain samples were used for heme oxygenase-1 (HO-1) and dopamine- and cAMP-regulated phosphoprotein (DARPP-32) Mr 32 kDa immunohistochemistry. Rats within the SAH group had higher mean whole brain (18)FDG SUV (2.349 ± 0.376 g/ml in the 3-h group and 2.453 ± 0.495 g/ml in the 12-h group) compared to that of sham (n = 3; mean SUV = 2.030 ± 0.247 g/ml; P < 0.05) or control groups (n = 3; mean SUV = 1.800 ± 0.484 g/ml; P < 0.05). Whole brain (18)FDG SUV did not vary significantly between rats imaged at 3 h vs. those imaged at 12 h post-SAH (P > 0.05). Regions of decreasing SUV in SAH rats correlated with neuronal death and increased expression of HO-1. Higher (18)FDG PET SUV was evident in rats post-SAH compared to sham and control groups. Regions of decreasing SUV in SAH rats correlated with neuronal death and increased HO-1 expression as evaluated by histopathology.

Genetic markers in the EET metabolic pathway are associated with outcomes in patients with aneurysmal subarachnoid hemorrhage

Preclinical studies show that epoxyeicosatrienoic acids (EETs) regulate cerebrovascular tone and protect against cerebral ischemia. We investigated the relationship between polymorphic genes involved in EET biosynthesis/metabolism, cytochrome P450 (CYP) eicosanoid levels, and outcomes in 363 patients with aneurysmal subarachnoid hemorrhage (aSAH). Epoxyeicosatrienoic acids and dihydroxyeicosatetraenoic acid (DHET) cerebrospinal fluid (CSF) levels, as well as acute outcomes defined by delayed cerebral ischemia (DCI) or clinical neurologic deterioration (CND), were assessed over 14 days. Long-term outcomes were defined by Modified Rankin Scale (MRS) at 3 and 12 months. CYP2C8*4 allele carriers had 44% and 36% lower mean EET and DHET CSF levels (P=0.003 and P=0.007) and were 2.2- and 2.5-fold more likely to develop DCI and CND (P=0.039 and P=0.041), respectively. EPHX2 55Arg, CYP2J2*7, CYP2C8*1B, and CYP2C8 g.36785A allele carriers had lower EET and DHET CSF levels. CYP2C8 g.25369T and CYP2C8 g.36755A allele carriers had higher EET levels. Patients with CYP2C8*2C and EPHX2 404del variants had worse long-term outcomes while those with EPHX2 287Gln, CYP2J2*7, and CYP2C9 g.816G variants had favorable outcomes. Epoxyeicosatrienoic acid levels were associated with Fisher grade and unfavorable 3-month outcomes. Dihydroxyeicosatetraenoic acids were not associated with outcomes. No associations passed Bonferroni multiple testing correction. These are the first clinical data demonstrating the association between the EET biosynthesis/metabolic pathway and the pathophysiology of aSAH.

Monitoring and sedation differences in the management of severe head injury and subarachnoid hemorrhage among neurocritical care centers

BACKGROUND

The emergence of specialized neurocritical care (NCC) centers has been associated with an improved survival of patients with severe traumatic brain injury or subarachnoid hemorrhage. However, there are no established guidelines on sedation strategy or the frequency of evaluating the level of consciousness using the neurological wake-up test (NWT) in sedated NCC patients.

OBJECTIVES

The aim was to compare the (1) monitoring techniques, (2) sedation principles, and (3) the use of the NWT in patients with severe traumatic brain injury or subarachnoid hemorrhage in 16 NCC centers.

METHOD

A systematic survey of all 16 centers providing NCC in Scandinavia was performed using a questionnaire regarding the routine primary choice of sedative and analgesic compounds, monitoring techniques, and the frequency of the NWT, sent to the director of each center during 1999, 2004, and 2009.

RESULTS

The response rate was 100%. Except for one center in 1999, all included centers routinely used monitoring of intracranial and cerebral perfusion pressure. In contrast, newer monitoring techniques such as microdialysis, jugular bulb oximetry, and brain tissue oxygenation were infrequently used throughout the survey period. Approximately half of the NCC centers used propofol infusion as the primary sedative, whereas the remaining centers used midazolam infusion, and there was a marked variation in the choice of analgesia in each evaluated year. The NWT was never used in 50% of centers and ≥six times daily in one center from 1999 to 2009. Most differences among the NCC centers remained unchanged over the evaluated 10-year period.

DISCUSSION

Although Scandinavian countries have similar healthcare systems, there were marked differences among the participating NCC centers in the choice of monitoring tools and sedatives and the routine use of the NWT. These differences likely reflect different clinical management traditions and a lack of evidence-based guidelines in routine NCC.

[The relationship between aneurysmal subarachnoid hemorrhage and meteorological parameters based on a series of 236 French patients]

Subarachnoid hemorrhage (SAH) is a sudden and potentially severe event with mortality rates ranging between 24 and 30 % depending on the initial clinical condition. Studies have attempted to assess the possible influence of meteorological parameters on the occurrence of SAH. However, this idea remains very controversial and the results vary widely from one study to another. Our study is the second largest French series, and first performed in a homogeneous series of patients. The aim of our study was to attempt to establish a relationship between the weather (i.e.) temperature variations and daily variations of atmospheric pressure in the days before the onset of SAH and the same day and the occurrence of non-traumatic SAH in a homogeneous population of 236 patients from a single center, over a period of 7 years (2002 to 2008). This retrospective study does not suggest any relationship between the occurrence of SAH and meteorological data studied. Moreover, no relationship was observed between mean changes in temperature or pressure and the occurrence of SAH, that the day of the bleeding or the days preceding the SAH. However, a female predominance was observed and a relatively high mortality rate of 18.3 %. The distribution of the occurrence of an SAH was random. As it seems impossible to provide logistics and organization of care for non-traumatic SAH, the care system must remain vigilant throughout the year.

Risk of intracranial hemorrhage associated with autosomal dominant polycystic kidney disease in patients with end stage renal disease

BACKGROUND

An analysis of intracranial hemorrhage (ICH) in a national sample of autosomal dominant polycystic kidney disease (ADPKD) patients receiving long-term dialysis has not been reported. It is often assumed that patients with ADPKD are not at increased risk of ICH after starting dialysis. We hypothesized that patients with ADPKD would have a higher subsequent risk of ICH even after the start of chronic dialysis.

METHODS

Retrospective cohort study of Medicare primary patients with and without ADPKD in the United States Renal Data System (USRDS), initiated on chronic dialysis or transplanted between 1 January 1999 and 3 July 2009, and followed until 31 December 2009. Covariates included age, gender, race, prior stroke, diabetes mellitus, dialysis modality, body mass index, serum albumin and other co-morbid conditions from the Medical Evidence Form. Primary outcome was ICH, based on inpatient and outpatient Medicare claims, and all-cause mortality. Kaplan-Meier analysis was used for unadjusted assessment of time to events. Cox regression was used for assessment of factors associated with ICH and mortality. We performed competing risk regression using kidney transplant and death as competing risks. Kidney transplant was also modeled as a time-dependent covariate in Cox regression.

RESULTS

Competing risk regression demonstrated that ADPKD had a subhazard ratio 2.97 for ICH (95% CI 2.27-3.89). Adjusted Cox analysis showed that ADPKD patients had an AHR for death of 0.59 vs. non-ADPKD patients (95% CI 0.57-0.61).

CONCLUSIONS

ADPKD is a significant risk factor for ICH among patients on maintenance dialysis. Our Medicare primary cohort was older than in previous studies of intracranial aneurysm rupture among ADPKD patients. There are also limitations inherent to using the USRDS database.

Knowledge, attitude and practice of stroke in India versus other developed and developing countries

Rising stroke and higher mortality among Indian population needs focused attention for prevention and early management of stroke. In India, very few studies have been carried out to determine the causes of deficiencies in knowledge, attitude and practice (KAP) of stroke among Indians. Study on KAP is essential to improve the awareness about stroke, early diagnosis and institution of appropriate management. In this article, we have reviewed the existing literature on this issue and tried to compare it with those of developed countries and suggested the measures we need to adopt in India to improve awareness and knowledge base.

The effect of intravenous interleukin-1 receptor antagonist on inflammatory mediators in cerebrospinal fluid after subarachnoid haemorrhage: a phase II randomised controlled trial

Background

Interleukin-1 (IL-1) is a key mediator of ischaemic brain injury induced by stroke and subarachnoid haemorrhage (SAH). IL-1 receptor antagonist (IL-1Ra) limits brain injury in experimental stroke and reduces plasma inflammatory mediators associated with poor outcome in ischaemic stroke patients. Intravenous (IV) IL-1Ra crosses the blood–brain barrier (BBB) in patients with SAH, to achieve cerebrospinal fluid (CSF) concentrations that are neuroprotective in rats.

Methods

A small phase II, double-blind, randomised controlled study was carried out across two UK neurosurgical centres with the aim of recruiting 32 patients. Adult patients with aneurysmal SAH, requiring external ventricular drainage (EVD) within 72 hours of ictus, were eligible. Patients were randomised to receive IL-1Ra (500 mg bolus, then a 10 mg/kg/hr infusion for 24 hours) or placebo. Serial samples of CSF and plasma were taken and analysed for inflammatory mediators, with change in CSF IL-6 between 6 and 24 hours as the primary outcome measure.

Results

Six patients received IL-1Ra and seven received placebo. Concentrations of IL-6 in CSF and plasma were reduced by one standard deviation in the IL-1Ra group compared to the placebo group, between 6 and 24 hours, as predicted by the power calculation. This did not reach statistical significance (P = 0.08 and P = 0.06, respectively), since recruitment did not reach the target figure of 32. No adverse or serious adverse events reported were attributable to IL-1Ra.

Conclusions

IL-1Ra appears safe in SAH patients. The concentration of IL-6 was lowered to the degree expected, in both CSF and plasma for patients treated with IL-1Ra.

Racial/ethnic differences in inpatient mortality and use of institutional postacute care following subarachnoid hemorrhage

Object

The goal of this study was to determine racial/ethnic differences in inpatient mortality rates and the use of institutional postacute care following subarachnoid hemorrhage (SAH) in the US.

Methods

A cross-sectional study of hospital discharges for SAH was conducted using the Nationwide Inpatient Sample for the years 2005–2010. Discharges with a principal diagnosis of SAH were identified and abstracted using the appropriate ICD-9-CM diagnostic code. Racial/ethnic groups were defined as white, black, Hispanic, Asian/Pacific Islander (API), and American Indian. Multinomial logistic regression analyses were performed comparing racial/ethnic groups with respect to the primary outcome of risk of in-hospital mortality and the secondary outcome of likelihood of discharge to institutional care.

Results

During the study period, 31,631 discharges were related to SAH. Race/ethnicity was a significant predictor of death (p = 0.003) and discharge to institutional care (p ≤ 0.001). In the adjusted analysis, compared with white patients, API patients were at higher risk of death (OR 1.34, 95% CI 1.13–1.59) and Hispanic patients were at lower risk of death (OR 0.84, 95% CI 0.72–0.97). The likelihood of discharge to institutional care was statistically similar between white, Hispanic, API, and Native American patients. Black patients were more likely to be discharged to institutional care compared with white patients (OR 1.27, 95% CI 1.14–1.40), but were similar to white patients in the risk of death.

Conclusions

Significant racial/ethnic differences are present in the risk of inpatient mortality and discharge to institutional care among patients with SAH in the US. Outcome is likely to be poor among API patients and best among Hispanic patients compared with other groups.

Effect of treatment with simvastatin and cyclosporine on neurotransmitter concentrations in cerebrospinal fluid after subarachnoid hemorrhage in dogs

OBJECTIVE

To measure concentrations of glutamate, aspartate, γ-aminobutyric acid (GABA), and glycine in CSF of dogs with experimentally induced subarachnoid hemorrhage (SAH) and to assess effects of cyclosporine and simvastatin on these concentrations.

SAMPLE

CSF samples from 13 dogs.

PROCEDURES

In a previous study, SAH was induced in dogs via 2 injections of autologous blood into the cerebellomedullary cistern 24 hours apart. Dogs were untreated (control; n = 5) or received simvastatin alone (4) or simvastatin in combination with cyclosporine (4). Samples of CSF were collected before the first blood injection (baseline; time 0), before the second blood injection, and on days 3, 7, and 10. For the study reported here, neurotransmitter concentrations in CSF were analyzed via high-performance liquid chromatography. Data were analyzed with a repeated-measures model with adjustments for multiple comparisons by use of the Tukey method.

RESULTS

In control dogs, the glutamate concentration peaked on day 3 and there was a significant increase in GABA and glutamate concentrations. Glutamate concentrations were significantly lower and glycine concentrations significantly higher on day 3 after administration of simvastatin alone or simvastatin in combination with cyclosporine, compared with concentrations for the control group. No significant differences in GABA and aspartate concentrations were detected among treatment groups at any time point.

CONCLUSIONS AND CLINICAL RELEVANCE

Glutamate concentrations were increased in the CSF of dogs with SAH. Simvastatin administration attenuated high glutamate concentrations. A combination of immunosuppression and upregulation of nitric oxide synthase may be useful in lowering high glutamate concentrations in ischemic CNS conditions.

Effect of Socioeconomic Status on Inpatient Mortality and Use of Postacute Care After Subarachnoid Hemorrhage

Background and Purpose—

Studies in the United States and Canada have demonstrated socioeconomic gradients in outcomes of acute life-threatening cardiovascular and cerebrovascular diseases. The extent to which these findings are applicable to subarachnoid hemorrhage is uncertain. This study investigated socioeconomic status-related differences in risk of inpatient mortality and use of institutional postacute care after subarachnoid hemorrhage in the United States and Canada.

Methods—

Subarachnoid hemorrhage patient records in the US Nationwide Inpatient Sample database (2005–2010) and the Canadian Discharge Abstract Database (2004–2010) were analyzed separately, and summative results were compared. Both databases are nationally representative and contain relevant sociodemographic, diagnostic, procedural, and administrative information. We determined socioeconomic status on the basis of estimated median household income of residents for patient’s ZIP or postal code. Multinomial logistic regression models were fitted with adjustment for relevant confounding covariates.

Results—

The cohort consisted of 31 631 US patients and 16 531 Canadian patients. Mean age (58 years) and crude inpatient mortality rates (22%) were similar in both countries. A significant income–mortality association was observed among US patients (odds ratio, 0.77; 95% CI, 0.65–0.93), which was absent among Canadian patients (odds ratio, 0.97; 95% CI, 0.85–1.12). Neighborhood income status was not significantly associated with use of postacute care in the 2 countries.

Conclusions—

Socioeconomic status is associated with subarachnoid hemorrhage inpatient mortality risk in the United States, but not in Canada, although it does not influence the pattern of use of institutional care among survivors in both countries.

Early endovascular treatment of subarachnoid hemorrhage

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

[Subarachnoidal hemorrhage and multiple vascular cerebral abnormalities in β-thalassemia major]

β-thalassemia is a genetic hemoglobinopathy, which can cause hypercoagulability, vessel wall damages and thromboembolic events. Spontaneous subarachnoidal hemorrhages are not commonly described in this affection. We report subarachnoidal hemorrhage, observed during the post-partum period in a 27-year-old woman suffering from β-thalassemia major. Brain MRI revealed complex vascular abnormalities: intracranial carotid occlusion, carotid micro-aneurisms, abnormally developed deep perforators and cortical arteries.

[Aneurysmal subarachnoid hemorrhage]

Acute subarachnoid hemorrhage (SAH) is a severe and acute life-threatening cerebrovascular disease. Approximately 80% of all acute non-traumatic SAHs are the result of a ruptured cerebrovascular aneurysm. Despite advances in diagnosis and treatment a high morbidity and mortality still exists. Apart from the primary cerebral damage there are also secondary complications, such as vasospasm, rebleeding, hydrocephalus, cerebral edema or hydrocephalus. For an appropriate therapy an understanding of the extensive pathophysiology, the options in diagnostics and therapy and the complications of the disease are essential. Anesthesiologists are decisively involved in the therapy of the primary and secondary damages and subsequently in the outcome as well. This article provides an overview of the perioperative and intensive care management of patients with SAH.

Intracranial hemorrhage

Intracranial hemorrhage refers to any bleeding within the intracranial vault, including the brain parenchyma and surrounding meningeal spaces. This article focuses on the acute diagnosis and management of primary nontraumatic intracerebral hemorrhage and subarachnoid hemorrhage in the emergency department.

Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJECTIVE

To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment.

MATERIAL AND METHODS

A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed.

RESULTS

The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm.

CONCLUSIONS

SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

Kallikrein 6 as a serum prognostic marker in patients with aneurysmal subarachnoid hemorrhage

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating condition that frequently causes death or significant disabilities. Blood tests to predict possible early complications could be very useful aids for therapy. The aim of this study was to analyze serum levels of kallikrein 6 (KLK6) in individuals with aSAH to determine the relevance of this protease with the outcome of these patients.

Methodology/Principal Findings

A reference interval for KLK6 was established by using serum samples (n = 136) from an adult population. Additionally, serum samples (n = 326) from patients with aSAH (n = 13) were collected for 5 to 14 days, to study the concentration of KLK6 in this disease. The correlation between KLK6 and S100B, an existing brain damage biomarker, was analyzed in 8 of 13 patients. The reference interval for KLK6 was established to be 1.04 to 3.93 ng/mL. The mean levels in patients with aSAH within the first 56 hours ranged from 0.27 to 1.44 ng/mL, with lowest levels found in patients with worse outcome. There were significant differences between patients with good recovery or moderate disability (n = 8) and patients with severe disability or death (n = 5) (mean values of 1.03 ng/mL versus 0.47 ng/mL, respectively) (p<0.01). There was no significant correlation between KLK6 and S100B.

Conclusions/Significance

Decreased serum concentrations of KLK6 are found in patients with aSAH, with the lowest levels in patients who died.

Intracranial hemorrhage in adult patients with hematological malignancies

BACKGROUND

Clinical characteristics and outcomes of intracranial hemorrhage (ICH) among adult patients with various hematological malignancies are limited.

METHODS

A total of 2,574 adult patients diagnosed with hematological malignancies admitted to a single university hospital were enrolled into this study between 2001 and 2010. The clinical characteristics, image reports and outcomes were retrospectively analyzed.

RESULTS

A total of 72 patients (48 men and 24 women) with a median age of 56 (range 18 to 86) had an ICH. The overall ICH incidence was 2.8% among adult patients with hematological malignancies. The incidence of ICH was higher in acute myeloid leukemia (AML) patients than in patients with other hematological malignancies (6.3% vs 1.1%, P = 0.001). ICH was more common among patients with central nervous system (CNS) involvement of lymphoma than among patients with CNS involved acute leukemia (P <0.001). Sites of ICH occurrence included the cerebral cortex (60 patients, 83%), basal ganglia (13 patients, 18%), cerebellum (10 patients, 14%), and brainstem (5 patients, 7%). A total of 33 patients (46%) had multifocal hemorrhages. In all, 56 patients (77%) had intraparenchymal hemorrhage, 22 patients (31%) had subdural hemorrhage, 15 patients (21%) had subarachnoid hemorrhage (SAH), and 3 patients (4%) had epidural hemorrhage. A total of 22 patients had 2 or more types of ICH. In all, 46 (64%) patients died of ICH within 30 days of diagnosis, irrespective of the type of hematological malignancy. Multivariate analysis revealed three independent prognostic factors: prolonged prothrombin time (P = 0.008), SAH (P = 0.021), and multifocal cerebral hemorrhage (P = 0.026).

CONCLUSIONS

The incidence of ICH in patients with AML is higher than patients with other hematological malignancies. But in those with intracranial malignant disease, patients with CNS involved lymphoma were more prone to ICH than patients with CNS involved acute leukemia. Mortality was similar regardless of the type of hematological malignancy. Neuroimaging studies of the location and type of ICH could assist with prognosis prediction for patients with hematological malignancies.

High dose erythropoietin increases brain tissue oxygen tension in severe vasospasm after subarachnoid hemorrhage

Background

Vasospasm-related delayed cerebral ischemia (DCI) significantly impacts on outcome after aneurysmal subarachnoid hemorrhage (SAH). Erythropoietin (EPO) may reduce the severity of cerebral vasospasm and improve outcome, however, underlying mechanisms are incompletely understood. In this study, the authors aimed to investigate the effect of EPO on cerebral metabolism and brain tissue oxygen tension (P_btO₂).

Methods

Seven consecutive poor grade SAH patients with multimodal neuromonitoring (MM) received systemic EPO therapy (30.000 IU per day for 3 consecutive days) for severe cerebral vasospasm. Cerebral perfusion pressure (CPP), mean arterial blood pressure (MAP), intracranial pressure (ICP), P_btO₂ and brain metabolic changes were analyzed during the next 24 hours after each dose given. Statistical analysis was performed with a mixed effects model.

Results

A total of 22 interventions were analyzed. Median age was 47 years (32–68) and 86 % were female. Three patients (38 %) developed DCI. MAP decreased 2 hours after intervention (P < 0.04) without significantly affecting CPP and ICP. P_btO₂ significantly increased over time (P < 0.05) to a maximum of 7 ± 4 mmHg increase 16 hours after infusion. Brain metabolic parameters did not change over time.

Conclusions

EPO increases P_btO₂ in poor grade SAH patients with severe cerebral vasospasm. The effect on outcome needs further investigation.

Clipping vs. coiling in acute aneurysmal subarachnoid haemorrhage: Should the patient's medical condition influence treatment modality?

INTRODUCTION

Acute subarachnoid haemorrhage (SAH) resulting from aneurysmal rupture is a medical condition associated with significant morbidity and mortality. Medical complications resulting from the bleeding itself, along with the patient's underlying medical conditions are known to represent possible prognostic factors in acute SAH. However, their respective significance on the patient's overall clinical outcome following either endovascular coiling (EC) or surgical clipping (SC) remains to be ascertained as well as their potential role in choosing a definitive treatment option. We thus reviewed the evidence concerning the patient's medical condition as a factor in this decision making process.

METHODOLOGY

Source data were obtained from a MEDLINE search of the medical literature and by manual review of published randomised trials comparing EC to SC.

RESULTS

The last three decades allowed for detection of medical complications with increasing frequency in the context of SAH, as awareness for them has improved. Despite the fact that a patient's extra-neurological condition can be a significant prognostic factor after a SAH, our review demonstrates that medical conditions in general were not taken into consideration in randomized trials comparing EC to SC. Also, we found no analysis comparing the potential role of prior versus post-SAH medical conditions in choosing either therapeutic avenue.

CONCLUSION

It is not determined whether it is appropriate for SAH patients to be offered treatment for a ruptured aneurysm based mostly on anatomical criteria or if, within certain subgroups of patients, EC and SC should also be recommended in light of what the patient can tolerate from a medical standpoint. Although we hypothesize that in practice, the patient's medical condition is considered in the decision making process, it remains to be documented. Patient, aneurysm and institution-related factors are all interrelated, as is patient care. Data on all of these factors are thus needed and their analysis by association rather than by dissociation may be the key in answering our question.

Expression and role of COMT in a rat subarachnoid hemorrhage model

OBJECTIVE

The present study aimed to investigate the expression of COMT mRNA and protein and detect the plasma content of catecholamine (CA), the diameter and thickness of the basilar artery in the early stage of subarachnoid hemorrhage (SAH) to explore the role of COMT in SAH.

METHODS

SAH was induced by injection of nonheparinized autologous arterial blood into the chiasmatic cistern. RT-PCR and Western blotting were used to detect the mRNA and protein levels of COMT in the rat striatum at different time points (6, 12, 24, 48, and 72 h after SAH). High performance liquid chromatography was performed to detect plasma CA. With HE staining, the basilar artery diameter and its thickness were measured.

RESULTS

Compared with the normal group and sham group, the increased expression of mRNA and protein of COMT began at 6 h after SAH (P<0.01), which peaked at 12 h (P<0.01); it began to drop 24 h after SAH (P<0.01). However, 48 h after SAH, the level of COMT (mRNA and protein) was still higher than that of the normal group (P<0.01). Three days after SAH, the expression of COMT nearly reached normal levels (P>0.05). For rats undergoing SAH, plasma CA began to increase 6h after injury, which reached a maximum at 24 h after SAH, and then started to drop. Three days later, it still remained elevated compared with that of the normal group and sham group (P<0.01). The most marked contraction and increased wall thickness of the basilar artery were found at 24 h after SAH (P<0.01), which at least lasted for 2 days (P<0.01), and 72 h after injury, the diameter and thickness of the basilar artery almost reached normal levels (P>0.05).

CONCLUSION

(1) SAH could induce the expression of COMT in the rat striatum in the early stage. (2) Plasma CA levels were significantly elevated in the early stage of SAH accompanied by cerebrovascular vasospasm (CVS). (3) In the early stage of SAH, increased plasma and CVS may be associated with the insufficient increase and persistence of COMT expression.

Impact of systemic inflammatory response syndrome on vasospasm, cerebral infarction, and outcome after subarachnoid hemorrhage: exploratory analysis of CONSCIOUS-1 database

BACKGROUND

Systemic inflammatory response syndrome (SIRS) may develop after aneurysmal subarachnoid hemorrhage (SAH). We investigated factors associated with SIRS after SAH, whether SIRS was associated with complications of SAH such as vasospasm, cerebral infarction, and clinical outcome, and whether SIRS could contribute to a difference in outcome between patients treated by endovascular coiling or neurosurgical clipping of the ruptured aneurysm.

METHODS

This was exploratory analysis of 413 patients in the CONSCIOUS-1 study. SIRS was diagnosed if the patient had at least 2 of 4 variables (hypothermia/fever, tachycardia, tachypnea, and leukocytosis/leukopenia) within 4 days of admission. Clinical outcome was measured on the Glasgow outcome scale 3 months after SAH. The relationship between clinical and radiologic variables and SIRS, angiographic vasospasm, delayed ischemic neurologic deficit (DIND), cerebral infarction, vasospasm-related infarction, and clinical outcome were modeled with uni- and multivariable analyses.

RESULTS

63% of patients developed SIRS. Many factors were associated with SIRS in univariate analysis, but only poor WFNS grade and pneumonia were independently associated with SIRS in multivariable analysis. SIRS burden (number of SIRS variables per day over the first 4 days) was associated with poor outcome, but not with angiographic vasospasm, DIND, or cerebral infarction. The method of aneurysm treatment was not associated with SIRS.

CONCLUSION

SIRS was associated with poor outcome but not angiographic vasospasm, DIND, or cerebral infarction after SAH in the CONSCIOUS-1 data. There was no support for the notion that neurosurgical clipping is associated with a greater risk of SIRS than endovascular coiling.

Participation of KCNQ (Kv7) potassium channels in myogenic control of cerebral arterial diameter

KCNQ gene expression was previously shown in various rodent blood vessels, where the products of KCNQ4 and KCNQ5, Kv7.4 and Kv7.5 potassium channel subunits, respectively, have an influence on vascular reactivity. The aim of this study was to determine if small cerebral resistance arteries of the rat express KCNQ genes and whether Kv7 channels participate in the regulation of myogenic control of diameter. Quantitative reverse transcription polymerase chain reaction (QPCR) was undertaken using RNA isolated from rat middle cerebral arteries (RMCAs) and immunocytochemistry was performed using Kv7 subunit-specific antibodies and freshly isolated RMCA myocytes. KCNQ4 message was more abundant than KCNQ5 = KCNQ1, but KCNQ2 and KCNQ3 message levels were negligible. Kv7.1, Kv7.4 and Kv7.5 immunoreactivity was present at the sarcolemma of freshly isolated RMCA myocytes. Linopirdine (1 microm) partially depressed, whereas the Kv7 activator S-1 (3 and/or 20 microm) enhanced whole-cell Kv7.4 (in HEK 293 cells), as well as native RMCA myocyte Kv current amplitude. The effects of S-1 were voltage-dependent, with progressive loss of stimulation at potentials of >15 mV. At the concentrations employed linopirdine and S-1 did not alter currents due to recombinant Kv1.2/Kv1.5 or Kv2.1/Kv9.3 channels (in HEK 293 cells) that are also expressed by RMCA myocytes. In contrast, another widely used Kv7 blocker, XE991 (10 microm), significantly attenuated native Kv current and also reduced Kv1.2/Kv1.5 and Kv2.1/Kv9.3 currents. Pressurized arterial myography was performed using RMCAs exposed to intravascular pressures of 10-100 mmHg. Linopirdine (1 microm) enhanced the myogenic response at 20 mmHg, whereas the activation of Kv7 channels with S-1 (20 microm) inhibited myogenic constriction at >20 mmHg and reversed the increased myogenic response produced by suppression of Kv2-containing channels with 30 nm stromatoxin (ScTx1). These data reveal a novel contribution of KCNQ gene products to the regulation of myogenic control of cerebral arterial diameter and suggest that Kv7 channel activating drugs may be appropriate candidates for the development of an effective therapy to ameliorate cerebral vasospasm.

Knowledge of stroke risk factors among primary care patients with previous stroke or TIA: a questionnaire study

Background

Survivers of stroke or transient ischaemic attacks (TIA) are at risk of new vascular events. Our objective was to study primary health care patients with stroke/TIA regarding their knowledge about risk factors for having a new event of stroke/TIA, possible associations between patient characteristics and patients' knowledge about risk factors, and patients' knowledge about their preventive treatment for stroke/TIA.

Methods

A questionnaire was distributed to 240 patients with stroke/TIA diagnoses, and 182 patients (76%) responded. We asked 13 questions about diseases/conditions and lifestyle factors known to be risk factors and four questions regarding other diseases/conditions ("distractors"). The patients were also asked whether they considered each disease/condition to be one of their own. Additional questions concerned the patients' social and functional status and their drug use. The t-test was used for continuous variables, chi-square test for categorical variables, and a regression model with variables influencing patient knowledge was created.

Results

Hypertension, hyperlipidemia and smoking were identified as risk factors by nearly 90% of patients, and atrial fibrillation and diabetes by less than 50%. Few patients considered the distractors as stroke/TIA risk factors (3-6%). Patients with a family history of cardiovascular disease, and patients diagnosed with carotid stenosis, atrial fibrillation or diabetes, knew these were stroke/TIA risk factors to a greater extent than patients without these conditions. Atrial fibrillation or a family history of cardiovascular disease was associated with better knowledge about risk factors, and higher age, cerebral haemorrhage and living alone with poorer knowledge. Only 56% of those taking anticoagulant drugs considered this as intended for prevention, while 48% of those taking platelet aggregation inhibitors thought this was for prevention.

Conclusions

Knowledge about hypertension, hyperlipidemia and smoking as risk factors was good, and patients who suffered from atrial fibrillation or carotid stenosis seemed to be well informed about these conditions as risk factors. However, the knowledge level was low regarding diabetes as a risk factor and regarding the use of anticoagulants and platelet aggregation inhibitors for stroke/TIA prevention. Better teaching strategies for stroke/TIA patients should be developed, with special attention focused on diabetic patients.

Trends in Case-Fatality Rates in Hospitalized Nontraumatic Subarachnoid Hemorrhage: Results of a Population-Based Study in Dijon, France, From 1985 to 2006

BACKGROUND

Subarachnoid hemorrhage accounts for 2% to 5% of all strokes and is associated with high morbidity and mortality rates. Reports in the literature show that case-fatality rates vary with time and according to geographical area.

OBJECTIVE

The objective of the study was to evaluate the case-fatality rates in subarachnoid hemorrhage at 1 and 6 months and to determine trends in these rates over 22 years using a population-based registry.

METHODS

The Dijon Stroke Registry has enabled us to perform a comprehensive analysis of subarachnoid hemorrhage diagnosed in a population of &gt;150 000 inhabitants hospitalized between 1985 and 2006 in the Dijon University Hospital, which has both a neurosurgery unit and a neuroradiology unit. Diagnosis was based on clinical and neuroimaging features and, when necessary, on lumbar puncture.

RESULTS

Case-fatality rates for hospitalized subarachnoid hemorrhages at 1 and 6 months were 15.59% (95% confidence interval [CI], 9.37–25.34) and 16.84% (95% CI, 10.33–26.78), respectively. From 1985 to 1995, case-fatality rates for SAH at 1 and 6 months were 17.1% (95% CI, 8.1–34.2) and 17.7% (95% CI, 9.6–31.3), whereas from 1996 to 2006, they were 20.2% (95% CI, 10.2–37.8) and 19.7% (95% CI, 11.1–33.6), respectively.

CONCLUSION

Case-fatality rates for hospitalized subarachnoid hemorrhages in this population-based study remained stable over 22 years, suggesting that this stroke subtype is still a very severe disease despite early management. Most deaths occurred during the first 30 days. Further work is necessary to evaluate levels of prehospital case-fatality in our population-based registry.

NOX enzymes in the central nervous system: from signaling to disease

Oxidative stress has been implicated in the pathogenesis of neurologic and psychiatric diseases. The brain is particularly vulnerable to oxidative damage due to high oxygen consumption, low antioxidant defense, and an abundance of oxidation-sensitive lipids. Production of reactive oxygen species (ROS) by mitochondria is generally thought to be the main cause of oxidative stress. However, a role for ROS-generating NADPH oxidase NOX enzymes has recently emerged. Activation of the phagocyte NADPH oxidase NOX2 has been studied mainly in microglia, where it plays a role in inflammation, but may also contribute to neuronal death in pathologic conditions. However, NOX-dependent ROS production can be due to the expression of other NOX isoforms, which are detected not only in microglia, but also in astrocytes and neurons. The physiologic and pathophysiologic roles of such NOX enzymes are only partially understood. In this review, we summarize the present knowledge about NOX enzymes in the central nervous system and their involvement in neurologic and psychiatric diseases.