Effect of premorbid hypertension control on outcome of patients with aneurysmal subarachnoid hemorrhage

The impact of systolic blood pressure reduction on aneurysm re-bleeding in subarachnoid hemorrhage: A systematic review and meta-analysis

BACKGROUND

Preventing early aneurysm rebleeding is crucial in the management of aneurysmal subarachnoid hemorrhage (SAH). Lowering systolic blood pressure (SBP) has been proposed as a potential strategy, but the evidence remains inconclusive. This systematic review and meta-analysis aimed to determine if a specific SBP target could reduce the risk of aneurysm rebleeding prior to treatment.

METHODS

Electronic databases were systematically searched for studies comparing SBP between SAH patients with and without aneurysm rebleeding before surgical treatment. Data on SBP values, patient characteristics, and rebleeding events were extracted. Meta-analyses were performed to pool mean SBP differences and odds ratios (ORs) for rebleeding at different SBP cut-offs.

RESULTS

Ten studies were included in the systematic review. Pooled data from the included studies showed that the mean SBP was higher in the rebleeding group (mean difference 5.89, 95 % CI 1.94 to 9.85). SBP ≤160 mmHg was associated with lower rebleeding risk (OR 0.30, 95 % CI 0.14 to 0.65). However, substantial heterogeneity and limitations in study designs and definitions were noted.

CONCLUSIONS

This meta-analysis suggests that SAH patients with rebleeding may present with higher SBP. However, the findings should be interpreted cautiously due to study limitations. Future prospective studies with standardized definitions and comprehensive data collection are needed to elucidate the complex relationship between blood pressure dynamics and rebleeding risk in SAH.

Impact of premorbid hypertension and renin-angiotensin-aldosterone system inhibitors on the severity of aneurysmal subarachnoid haemorrhage: a multicentre study

BACKGROUND

Hypertension is widely acknowledged as a significant contributory factor to the heightened risk of intracranial aneurysm rupture. Nevertheless, the impact of hypertension management on the outcomes subsequent to aneurysmal subarachnoid haemorrhage (aSAH), particularly concerning the severity of aSAH, remains an underexplored area.

METHODS

We conducted a retrospective analysis using data from a prospectively multicentre cohort of 4545 patients with aSAH in China. Premorbid hypertension status and the utilisation of antihypertensive medications prior to admission were set as key exposure factors. The primary outcomes encompassed unfavourable clinical grading scales observed on admission. Employing multivariable logistic regression, we explored the association between premorbid hypertension status, preadmission use of renin-angiotensin-aldosterone system (RAAS) inhibitors and unfavourable clinical grading scales.

RESULTS

In comparison to patients with normal blood pressure, only uncontrolled hypertension demonstrated a significant and independent association with an elevated risk of poor outcomes on the Hunt-Hess scale (OR=1.799, 95% CI 1.413 to 2.291, p<0.001) and the World Federation of Neurological Surgeons (WFNS) scale (OR=1.721, 95% CI 1.425 to 2.079, p<0.001). Furthermore, the antecedent use of RAAS inhibitors before admission was markedly and independently linked to a diminished risk of adverse outcomes on the Hunt-Hess scale (OR=0.653, 95% CI 0.430 to 0.992, p=0.046) and the WFNS scale (OR=0.656, 95% CI 0.469 to 0.918, p=0.014).

CONCLUSIONS

Uncontrolled hypertension markedly elevates the risk of adverse clinical outcomes following an aSAH. Conversely, the preadmission utilisation of RAAS inhibitors demonstrates a noteworthy association with a favourable clinical outcome after aSAH.

Clinical Analysis of Poor Outcomes After Surgery for Aneurysmal Subarachnoid Hemorrhage in Guizhou, China

OBJECTIVE

To investigate poor outcomes of aneurysmal subarachnoid hemorrhage (aSAH) and compare the clinicodemographic characteristics, imaging features, intervention strategies, laboratory tests, and complications of patients with good and poor outcomes to identify potential risk factors.

METHODS

We retrospectively analyzed patients with aSAH who underwent surgery in Guizhou, China, between June 1, 2014, and September 1, 2022. The Glasgow Outcome Scale was used to evaluate outcomes at discharge, with scores of 1-3 and 4-5 considered poor and good, respectively. Clinicodemographic characteristics, imaging features, intervention strategies, laboratory tests, and complications were compared between patients with good and poor outcomes. Multivariate analysis was used to determine independent risk factors for poor outcomes. The poor outcome rate of each ethnic group was compared.

RESULTS

Of 1169 patients, 348 were ethnic minorities, 134 underwent microsurgical clipping, and 406 had poor outcomes at discharge. Patients with poor outcomes were older, represented fewer ethnic minorities, had a history of comorbidities, experienced more complications, and underwent microsurgical clipping. The top 3 types of aneurysms were anterior, posterior communicating, and middle cerebral artery aneurysms.

CONCLUSIONS

Outcomes at discharge varied according to ethnic group. Han patients had worse outcomes. Age, loss of consciousness at onset, systolic blood pressure on admission, Hunt-Hess grade 4-5 on admission, epileptic seizures, modified Fisher grade 3-4, microsurgical clipping, size of the ruptured aneurysm, and cerebrospinal fluid replacement were independent risk factors for aSAH outcomes.

Microsurgery versus embolization: different risk factors for short- and longterm outcomes of patients with ruptured aneurysms

PURPOSE

To evaluate the risk factors for poor outcomes after surgical and endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Patients with ≥ 18-years of age and aSAH were included, while patients who died within 12 h of admission or lost follow-up were excluded. All participants underwent standardized clinical and radiological assessment on admission and were reassessed at discharge and at 6-months follow-up using the Glasgow Outcome Scale (GOS).

RESULTS

Death at discharge was associated with female gender, anterior communication artery (ACoA) aneurysm location and presence of atherosclerotic plaque in the surgical group, and with age in the endovascular group. Both groups had clinical condition on follow-up associated with mFisher score on admission and hypertension. GOS on follow-up was also associated with presence of atherosclerotic plaque and multiple aneurysms in surgical group, and with age in endovascular group.

CONCLUSIONS

Subjects treated surgically are prone to unfavorable outcomes if atherosclerotic plaques and multiple aneurysms are present. In patients with endovascular treatment, age was the main predictor of clinical outcome.

Role of endothelial nitric oxide synthase for early brain injury after subarachnoid hemorrhage in mice

The first few hours and days after subarachnoid hemorrhage (SAH) are characterized by cerebral ischemia, spasms of pial arterioles, and a significant reduction of cerebral microperfusion, however, the mechanisms of this early microcirculatory dysfunction are still unknown. Endothelial nitric oxide production is reduced after SAH and exogenous application of NO reduces post-hemorrhagic microvasospasm. Therefore, we hypothesize that the endothelial NO-synthase (eNOS) may be involved in the formation of microvasospasms, microcirculatory dysfunction, and unfavorable outcome after SAH. SAH was induced in male eNOS deficient (eNOS^-/-) mice by endovascular MCA perforation. Three hours later, the cerebral microcirculation was visualized using in vivo 2-photon-microscopy. eNOS^-/- mice had more severe SAHs, more severe ischemia, three time more rebleedings, and a massively increased mortality (50 vs. 0%) as compared to wild type (WT) littermate controls. Three hours after SAH eNOS^-/- mice had fewer perfused microvessels and 40% more microvasospasms than WT mice. The current study indicates that a proper function of eNOS plays a key role for a favorable outcome after SAH and helps to explain why patients suffering from hypertension or other conditions associated with impaired eNOS function, have a higher risk of unfavorable outcome after SAH.

Nomogram for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage in the Chinese population

BACKGROUND

Delayed cerebral ischemia is a serious complication of aneurysmal subarachnoid hemorrhage with debilitating and fatal consequences. Lack of well-established risk factors impedes early identification of high-risk patients with delayed cerebral ischemia. A nomogram provides personalized, evidence-based, and accurate risk estimation. To offset the lack of a predictive tool, we developed a nomogram to predict delayed cerebral ischemia before performing surgical interventions for aneurysmal subarachnoid hemorrhage to aid surgical decision-making.

METHODS

We retrospectively collected data from 887 consecutive eligible Chinese patients who underwent surgical clipping or endovascular coiling for aneurysmal subarachnoid hemorrhage. Patients who previously underwent surgery formed the training cohort (n = 621) for nomogram development; those who underwent surgery later formed the validation cohort (n = 266) to confirm the performance of the model. A multivariate logistic regression analysis identified the independent risk factors associated with delayed cerebral ischemia, which were then incorporated into the nomogram.

RESULTS

Delayed cerebral ischemia was identified in 158/621 patients (25.4%) in the training cohort and in 66/266 patients (24.8%) in the validation cohort. Preoperative factors associated with delayed cerebral ischemia were age > 65 years, modified Fisher grade of 3-4, ruptured aneurysm in the anterior circulation, Hunt-Hess grade of 4-5, high blood pressure on admission, and plasma homocysteine level ≥ 10 μmol/L. Incorporating these six factors in the nomogram achieved efficient concordance indices of 0.73 (95% confidence interval, 0.68-0.77) and 0.65 (95% confidence interval, 0.57-0.72) in predicting delayed cerebral ischemia in the training and validation cohorts, respectively.

CONCLUSIONS

Our model can help determine an individual's risk of developing delayed cerebral ischemia in the Chinese population, and thereby, facilitate reasonable treatment-related decision-making.