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Scibilia A, Rustici A, Linari M, Zenesini C, Belotti LMB, Dall’Olio M, Princiotta C, Cuoci A, Aspide R, Migliorino E, Moneti M, Sturiale C, Castioni CA, Conti A, Bortolotti C, Cirillo L. Factors affecting 30-day mortality in poor-grade aneurysmal subarachnoid hemorrhage: a 10-year single-center experience. Front Neurol 2024; 15:1286862. [PMID: 38426166 PMCID: PMC10901988 DOI: 10.3389/fneur.2024.1286862] [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: 08/31/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024] Open
Abstract
Background The management of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is burdened by an unfavorable prognosis even with aggressive treatment. The aim of the present study is to investigate the risk factors affecting 30-day mortality in poor-grade aSAH patients. Methods We performed a retrospective analysis of a prospectively collected database of poor-grade aSAH patients (World Federation of Neurosurgical Societies, WFNS, grades IV and V) treated at our institution from December 2010 to December 2020. For all variables, percentages of frequency distributions were analyzed. Contingency tables (Chi-squared test) were used to assess the association between categorical variables and outcomes in the univariable analysis. Multivariable analysis was performed by using the multiple logistic regression method to estimate the odds ratio (OR) for 30-day mortality. Results A total of 149 patients were included of which 32% had WFNS grade 4 and 68% had WFNS grade 5. The overall 1-month mortality rate was 21%. On univariable analysis, five variables were found to be associated with the likelihood of death, including intraventricular hemorrhage (IVH ≥ 50 mL, p = 0.005), the total amount of intraventricular and intraparenchymal hemorrhage (IVH + ICH ≥ 90 mL, p = 0.019), the IVH Ratio (IVH Ratio ≥ 40%, p = 0.003), posterior circulation aneurysms (p = 0.019), presence of spot sign on initial CT scan angiography (p = 0.015).Nonetheless, when the multivariable analysis was performed, only IVH Ratio (p = 0.005; OR 3.97), posterior circulation aneurysms (p = 0.008; OR 4.05) and spot sign (p = 0.022; OR 6.87) turned out to be independent predictors of 30-day mortality. Conclusion The risk of mortality in poor-grade aSAH remains considerable despite maximal treatment. Notwithstanding the limitations of a retrospective study, our report highlights some neuroradiological features that in the emergency setting, combined with leading clinical and anamnestic parameters, may support the multidisciplinary team in the difficult decision-making process and communication with family members from the earliest stages of poor-grade aSAH. Further prospective studies are warranted.
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Affiliation(s)
- Antonino Scibilia
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
| | - Arianna Rustici
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOSI di Neuroradiologia Ospedale Maggiore, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Università di Bologna, Bologna, Italy
| | - Marta Linari
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Università di Bologna, Bologna, Italy
| | - Corrado Zenesini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unità di Epidemiologia e Biostatistica, Bologna, Italy
| | | | - Massimo Dall’Olio
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuroradiologia, Bologna, Italy
| | - Ciro Princiotta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuroradiologia, Bologna, Italy
| | - Andrea Cuoci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
| | - Raffaele Aspide
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Anestesia e Rianimazione, Bologna, Italy
| | - Ernesto Migliorino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Anestesia e Rianimazione, Bologna, Italy
| | - Manuel Moneti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Anestesia e Rianimazione, Bologna, Italy
| | - Carmelo Sturiale
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
| | - Carlo Alberto Castioni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Anestesia e Rianimazione, Bologna, Italy
| | - Alfredo Conti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Università di Bologna, Bologna, Italy
| | - Carlo Bortolotti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
| | - Luigi Cirillo
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuroradiologia, Bologna, Italy
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Autio AH, Paavola J, Tervonen J, Lång M, Elomaa AP, Huuskonen TJ, Huttunen J, Kärkkäinen V, von Und Zu Fraunberg M, Lindgren AE, Koivisto T, Kurola J, Jääskeläinen JE, Kämäräinen OP. Acute evacuation of 54 intracerebral hematomas (aICH) during the microsurgical clipping of a ruptured middle cerebral artery bifurcation aneurysm-illustration of the individual clinical courses and outcomes with a serial brain CT/MRI panel until 12 months. Acta Neurochir (Wien) 2024; 166:17. [PMID: 38231317 PMCID: PMC10794262 DOI: 10.1007/s00701-024-05902-9] [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: 10/08/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE In aneurysmal intracerebral hemorrhage (aICH), our review showed the lack of the patient's individual (i) timeline panels and (ii) serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. METHODS Our retrospective cohort consists of 54 consecutive aICH patients from a defined population who acutely underwent the clipping of a middle cerebral artery bifurcation saccular aneurysm (Mbif sIA) with the aICH evacuation at Kuopio University Hospital (KUH) from 2010 to 2019. We constructed the patient's individual timeline panels since the emergency call and serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. The patients were indicated by numbers (1.-54.) in the pseudonymized panels, tables, results, and discussion. RESULTS The aICH volumes on KUH admission (median 46 cm3) plotted against the time from the emergency call to the evacuation (median 8 hours) associated significantly with the rebleeds (n=25) and the deaths (n=12). The serial CT/MRI slice panels illustrated the aICHs, intraventricular hemorrhages (aIVHs), residuals after the aICH evacuations, perihematomal edema (PHE), delayed cerebral injury (DCI), and in the 42 survivors, the clinical outcome (mRS) and the brain tissue outcome. CONCLUSIONS Regarding aICH evacuations, serial brain CT/MRI panels present more information than words, figures, and graphs. Re-bleeds associated with larger aICH volumes and worse outcomes. Swift logistics until the sIA occlusion with aICH evacuation is required, also in duty hours and weekends. Intraoperative CT is needed to illustrate the degree of aICH evacuation. PHE may evoke uncontrollable intracranial pressure (ICP) in spite of the acute aICH volume reduction.
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Affiliation(s)
- Anniina H Autio
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
| | - Juho Paavola
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Joona Tervonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Maarit Lång
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Neurointensive Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Antti-Pekka Elomaa
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Terhi J Huuskonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jukka Huttunen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Virve Kärkkäinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Mikael von Und Zu Fraunberg
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Department of Neurosurgery, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Antti E Lindgren
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Timo Koivisto
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jouni Kurola
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Center for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Juha E Jääskeläinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Henry J, Dablouk MO, Kapoor D, Koustais S, Corr P, Nolan D, Coffey D, Thornton J, O'Hare A, Power S, Rawluk D, Javadpour M. Outcomes following poor-grade aneurysmal subarachnoid haemorrhage: a prospective observational study. Acta Neurochir (Wien) 2023; 165:3651-3664. [PMID: 37968366 DOI: 10.1007/s00701-023-05884-0] [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: 06/18/2023] [Accepted: 10/18/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Up to 35% of aneurysmal subarachnoid haemorrhage (aSAH) cases may present as poor grade, defined as World Federation of Neurosurgical Societies (WFNS) grades IV and V. In this study, we evaluate functional outcomes and prognostic factors. METHODS This prospective study included all patients referred to a national, centralized neurosurgical service with a diagnosis of poor-grade aSAH between 01/01/2016 and 31/12/2019. Multivariable logistic regression models were used to estimate probability of poor functional outcomes, defined as a Glasgow Outcome Scale (GOS) of 1-3 at 3 months. RESULTS Two hundred fifty-seven patients were referred, of whom 116/257 (45.1%) underwent treatment of an aneurysm, with 97/116 (84%) treated within 48 h of referral. Median age was 62 years (IQR 51-69) with a female predominance (167/257, 65%). Untreated patients tended to be older; 123/141 (87%) had WFNS V, 60/141 (45%) unreactive pupils and 21/141 (16%) circulatory arrest. Of all referred patients, poor outcome occurred in 169/230 (73.5%). Unreactive pupils or circulatory arrest conferred a universally poor prognosis, with mortality in 55/56 (98%) and 19/19 (100%), respectively. The risk of a poor outcome was 14.1% (95% CI 4.5-23.6) higher in WFNS V compared with WFNS IV. Age was important in patients without circulatory arrest or unreactive pupils, with risk of a poor outcome increasing by 1.8% per year (95% CI 1-2.7). In patients undergoing aneurysm securement, 48/101 (47.5%) had a poor outcome, with age, rebleeding, vasospasm and cerebrospinal fluid (CSF) diversion being important prognosticators. The addition of serum markers did not add significant discrimination beyond the clinical presentation. CONCLUSIONS The overall outcomes of WFNS IV and V aSAH remain poor, mainly due to the devastating effects of the original haemorrhage. However, in patients selected for aneurysm securement, good outcomes can be achieved in more than half of patients. Age, pre-intervention rebleeding, vasospasm, and CSF diversion are important prognostic factors.
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Affiliation(s)
- Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Mohammed O Dablouk
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dhruv Kapoor
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Stavros Koustais
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paula Corr
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Deirdre Nolan
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Deirdre Coffey
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - John Thornton
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Alan O'Hare
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Sarah Power
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Daniel Rawluk
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland.
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Autio AH, Paavola J, Tervonen J, Lång M, Huuskonen TJ, Huttunen J, Kärkkäinen V, von Und Zu Fraunberg M, Lindgren AE, Koivisto T, Kurola J, Jääskeläinen JE, Kämäräinen OP. Should individual timeline and serial CT/MRI panels of all patients be presented in acute brain insult cohorts? A pilot study of 45 patients with decompressive craniectomy after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:3299-3323. [PMID: 36715752 PMCID: PMC10624760 DOI: 10.1007/s00701-022-05473-7] [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: 07/28/2022] [Accepted: 12/20/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Our review of acute brain insult articles indicated that the patients' individual (i) timeline panels with the defined time points since the emergency call and (ii) serial brain CT/MRI slice panels through the neurointensive care until death or final brain tissue outcome at 12 months or later are not presented. METHODS We retrospectively constructed such panels for the 45 aneurysmal subarachnoid hemorrhage (aSAH) patients with a secondary decompressive craniectomy (DC) after the acute admission to neurointensive care at Kuopio University Hospital (KUH) from a defined population from 2005 to 2018. The patients were indicated by numbers (1.-45.) in the pseudonymized panels, tables, results, and discussion. The timelines contained up to ten defined time points on a logarithmic time axis until death ([Formula: see text]; 56%) or 3 years ([Formula: see text]; 44%). The brain CT/MRI panels contained a representative slice from the following time points: SAH diagnosis, after aneurysm closure, after DC, at about 12 months (20 survivors). RESULTS The timelines indicated re-bleeds and allowed to compare the times elapsed between any two time points, in terms of workflow swiftness. The serial CT/MRI slices illustrated the presence and course of intracerebral hemorrhage (ICH), perihematomal edema, intraventricular hemorrhage (IVH), hydrocephalus, delayed brain injury, and, in the 20 (44%) survivors, the brain tissue outcome. CONCLUSIONS The pseudonymized timeline panels and serial brain imaging panels, indicating the patients by numbers, allowed the presentation and comparison of individual clinical courses. An obvious application would be the quality control in acute or elective medicine for timely and equal access to clinical care.
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Affiliation(s)
- Anniina H Autio
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
| | - Juho Paavola
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Joona Tervonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Maarit Lång
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Neurointensive Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Terhi J Huuskonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jukka Huttunen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Virve Kärkkäinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Mikael von Und Zu Fraunberg
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Department of Neurosurgery, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Antti E Lindgren
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Timo Koivisto
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jouni Kurola
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Center for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Juha E Jääskeläinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Liu Z, Liu C, Ma K. Retrospective study on the correlation between serum MIF level and the condition and prognosis of patients with traumatic head injury. PeerJ 2023; 11:e15933. [PMID: 37645013 PMCID: PMC10461539 DOI: 10.7717/peerj.15933] [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: 03/15/2023] [Accepted: 07/30/2023] [Indexed: 08/31/2023] Open
Abstract
Objective This study aimed to investigate the correlation between serum levels of macrophage migration inhibitory factor (MIF) and the condition and prognosis of patients with traumatic brain injury (TBI). Methods A retrospective study design was used, and the clinical data of 131 TBI patients from February 2019 to January 2022 were analyzed. Patients were divided into mild (13-15 points), moderate (9-12 points), or severe (3-8 points) groups according to their Glasgow Coma Scale (GCS) score after admission. The serum levels of BDNF, MIF, and MBP in the three groups were compared, and their correlation with the severity of TBI was analyzed. Patients were then separated into a good prognosis group (4-5 points) and a poor prognosis group (≤3 points) based on their Glasgow Prognostic Score (GOS) after 6 months of follow-up. The predictive power of serum indexes and combined detection on prognosis was analyzed. Results Patients were classified into a mild group (n = 63), moderate group (n = 47), and severe group (n = 21) based on their GCS, with a significant difference noted in serum levels of MIF, MBP, and BDNF among patients with different degrees of severity (all P < 0.001). The MIF, MBP, and BDNF levels were lower in the mild group compared to the moderate (all P < 0.001) and severe group (all P < 0.001). Additionally, the MIF and BDNF levels in the moderate group were lower compared to the severe group (P = 0.011, P = 0.002). Patients with mild severity had lower serum MIF, MBP, and BDNF levels than those with other degrees, and these indexes were positively correlated with the severity of TBI (all P < 0.001, r = 0.62, r = 0.48, r = 0.58). Based on the GOS, patients were divided into a good prognosis group (n = 107) and a poor prognosis group (n = 24), with the levels of MIF, MBP, and BDNF in the good prognosis group being significantly lower than those in the poor prognosis group (P < 0.001, P = 0.007, P = 0.003). The area under the curve (AUC) of MIF was higher than that of MBP and BDNF in predicting the prognosis of TBI patients; however, the statistical differences were not significant (MIF vs. MBP, P = 0.239; MIF vs. BDNF, P = 0.211; BDNF vs. MBP, P = 0.899). The center line has a large displacement, CT annular cisterna compression, increased white blood cell count, MBP and BDNF were risk factors for prognosis in TBI patients (P = 0.005, P = 0.001, P = 0.005, P = 0.033, P = 0.044). Conclusion The serum levels of MIF, MBP, and BDNF in TBI patients were positively correlated with the severity of the disease, and MBP, BDNF levels had predictive value in determining patient prognosis.
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Affiliation(s)
- Zhentong Liu
- The Emergency Department, Qingdao Chengyang District People’s Hospital, Qingdao, China
| | - Chengwu Liu
- The Emergency Department, Qingdao Chengyang District People’s Hospital, Qingdao, China
| | - Kegao Ma
- The Emergency Department, Qingdao Chengyang District People’s Hospital, Qingdao, China
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Ahmetspahić A, Janković D, Burazerovic E, Rovčanin B, Šahbaz A, Hasanagić E, Džurlić A, Granov N, Feletti A. Clinical Characteristics of Poor-Grade Aneurysmal Subarachnoid Hemorrhage Treatment. Asian J Neurosurg 2023; 18:132-138. [PMID: 37056885 PMCID: PMC10089758 DOI: 10.1055/s-0043-1764118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Background The initial clinical status after aneurysm rupture, whether primary or secondary, determines the final outcome. The most common cause of patient deterioration is a high Hunt and Hess (HH) score, which correlates closely with a high mortality rate. Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is determined as an HH score 4 or 5. The aim of this study was to evaluate the clinical characteristics of poor graded aneurysmal SAH at our institution.
Patients and Methods During the 5-year period, 415 patients with intracranial aneurysm were admitted to our institution. Patients with poor-grade aneurysmal SAH accounted 31.08% (n = 132) of the total number of ruptured aneurysms. Interventional treatment was predominantly in the form of surgery, whereas conservative treatment included medication and external ventricular drainage. Final outcome was assessed with a modified Rankin score (mRs). Statistical analysis was performed using SPSS version 23.0 with a significance level set to 5% (α = 0.05).
Results The majority of patients (57.6%) were in the age range from 51 to 69 years. Twenty-five patients (18.9%) had an HH score of 4, whereas 107 patients (81.1%) had an HH score of 5. Depending on the location, the majority of patients (n = 43) had an aneurysm on the medial cerebral artery (MCA). The final aneurysm occlusion was performed in 71 patients, of whom 94.36% were treated surgically. A positive outcome (mRs 0–4) was found in 49.25% of patients who underwent primarily surgical, treatment with a mortality of 42.3%. Although the outcome was better in patients with an HH score 4, both groups benefited from surgical treatment.
Conclusion Poor-grade aneurismal SAH is a condition of the middle and older age, with most patients with an HH 5 score and deep comatose state. There was better outcome in patients with an HH score of 4 compared to an HH score of 5 and both groups benefited from surgical treatment, which resulted in a positive outcome in almost 50% of surgically treated patients.
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Hao G, Chu G, Pan P, Han Y, Ai Y, Shi Z, Liang G. Clinical effectiveness of nimodipine for the prevention of poor outcome after aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. Front Neurol 2022; 13:982498. [PMID: 36212656 PMCID: PMC9533126 DOI: 10.3389/fneur.2022.982498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/16/2022] [Indexed: 12/04/2022] Open
Abstract
Objective In clinical practice, nimodipine is used to control cerebral vasospasm (CVS), which is one of the major causes of severe disability and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the exact efficacy of nimodipine use for patients with aSAH is still controversial due to the lack of sufficient and up-to-date evidence. Methods In this meta-analysis, the latest databases of the Cochrane Central Register of Controlled Trials, PubMed-Medline, Web of Science, Embase, Scopus, and OVID-Medline were comprehensively searched for retrieving all randomized controlled trials (RCTs) regarding the efficacy of nimodipine in patients with aSAH. The primary outcome was a poor outcome, and the secondary outcomes were mortality and cerebral vasospasm (CVS). After detailed statistical analysis of different outcome variables, further evidence quality evaluation and recommendation grade assessment were carried out. Results Approximately 13 RCTs met the inclusion criteria, and a total of 1,727 patients were included. Meta-analysis showed that a poor outcome was significantly reduced in the nimodipine group [RR, 0.69 (0.60–0.78); I2 = 29%]. Moreover, nimodipine also dramatically decreased the mortality [RR, 0.50 (0.32–0.78); I2 = 62%] and the incidence of CVS [RR, 0.68 (0.46–0.99); I2 = 57%]. Remarkably, we found a poor outcome and mortality were both significantly lower among patients with aSAH, with the mean age < 50 than that mean age ≥ 50 by subgroup analysis. Furthermore, the evidence grading of a poor outcome and its age subgroup in this study was assessed as high. Conclusion Nimodipine can significantly reduce the incidence of a poor outcome, mortality, and CVS in patients with aSAH. Moreover, we strongly recommend that patients with aSAH, especially those younger than 50 years old, should use nimodipine as early as possible in order to achieve a better clinical outcome, whether oral medication or endovascular direct medication. Systematic review registration www.york.ac.uk/inst/crd, identifier: CRD42022334619.
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Hori S, Kashiwazaki D, Akioka N, Okamoto S, Kubo M, Horie Y, Kuwayama N, Kuroda S. Predictive Factors of Functional Outcome in World Federation of Neurosurgical Societies Grade V Subarachnoid Hemorrhage. World Neurosurg 2022; 165:e216-e222. [PMID: 35688368 DOI: 10.1016/j.wneu.2022.05.135] [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: 03/18/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) frequently have poor outcomes. The current understanding of the predictors of functional outcome only in WFNS grade V SAH is limited. METHODS Patients with WFNS grade V SAH were retrospectively analyzed between April 2008 and August 2019. Surgical treatment is commonly delayed until clinical improvement is observed using a less aggressive approach. Clinical and radiologic data on admission were assessed, and disease-related characteristics were compared between patients with favorable outcomes (modified Rankin Scale score 0-3) and those with unfavorable outcomes (modified Rankin Scale score 4-6). RESULTS A total of 144 patients were included, and 22 patients (15.3%) achieved favorable outcomes, whereas 122 patients (84.7%) had unfavorable outcomes. Surgical aneurysm repair was performed in all patients with favorable outcomes and in 21.3% of those with unfavorable outcomes. Multivariate analysis showed that Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and hypertension were significantly associated with unfavorable outcomes (odds ratio [OR], 9.54, P = 0.03; OR, 5.37, P = 0.04; OR, 11.80, P = 0.009; OR, 0.14, P = 0.02 and OR, 6.53, P = 0.04, respectively). CONCLUSIONS The final outcome of patients with WFNS grade V SAH was still poor and highly predicted by Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and a history of hypertension. The efficacy of aggressive surgical treatment for these patients remains controversial, and the indications should be clearly defined in patients with desolate clinical status on admission.
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Affiliation(s)
- Satoshi Hori
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan; Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan.
| | - Daina Kashiwazaki
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
| | - Naoki Akioka
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
| | - Soshi Okamoto
- Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan
| | - Michiya Kubo
- Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan
| | - Yukio Horie
- Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan
| | - Naoya Kuwayama
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
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Risk factors for intracranial aneurysm rupture in pediatric patients. Acta Neurochir (Wien) 2022; 164:1145-1152. [PMID: 34415443 DOI: 10.1007/s00701-021-04957-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/28/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intracranial aneurysm (IA) rupture in pediatric patients is a rare but fatal condition. Although risk factors for aneurysm rupture in adults have been well documented, they remain unknown in pediatric patients. METHODS Data for 94 pediatric patients with IAs were retrospectively analyzed. The patients were divided into ruptured and unruptured groups. Risk factors for aneurysm rupture were analyzed through univariable and multiple logistic regression analyses. Typical patients with risk factors were described. RESULTS Univariable analyses showed that the unruptured group had significantly higher percentages of giant aneurysms (43.2% vs 12.3%, P = 0.002), wide-neck aneurysms (67.6% vs 29.8%, P = 0.001), and aneurysms located in the internal carotid artery (40.5% vs 3.5%, P < 0.001), while the ruptured group had significantly higher percentages of patients younger than 5 years old (28.1% vs 5.4%, P = 0.013) and aneurysms located in the anterior cerebral artery (24.6% vs 5.4%, P = 0.032), posterior cerebral artery (14.0% vs 0%, P = 0.045), and distal arterial region (DAR) (46.8% vs 27.0%, P < 0.001). Multiple logistic regression analysis confirmed that age 0-5 years (OR = 6.844, P = 0.042) and IAs located in the DAR (OR = 4.162, P = 0.029) were independently related to an increased risk of rupture. Wide-necked aneurysms (OR = 0.235, P = 0.047) were independently associated with a lower risk of rupture. CONCLUSIONS Among pediatric patients, age younger than 5 years and lesions located in the DAR are independent risk factors for IA rupture, while an IA with a wide neck acts as a protective factor.
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Li YC, Wang R, A JY, Sun RB, Na SJ, Liu T, Ding XS, Ge WH. Cerebrospinal fluid metabolic profiling reveals divergent modulation of pentose phosphate pathway by midazolam, propofol and dexmedetomidine in patients with subarachnoid hemorrhage: a cohort study. BMC Anesthesiol 2022; 22:34. [PMID: 35086470 PMCID: PMC8793156 DOI: 10.1186/s12871-022-01574-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/20/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Agitation is common in subarachnoid hemorrhage (SAH), and sedation with midazolam, propofol and dexmedetomidine is essential in agitation management. Previous research shows the tendency of dexmedetomidine and propofol in improving long-term outcome of SAH patients, whereas midazolam might be detrimental. Brain metabolism derangement after SAH might be interfered by sedatives. However, how sedatives work and whether the drugs interfere with patient outcome by altering cerebral metabolism is unclear, and the comprehensive view of how sedatives regulate brain metabolism remains to be elucidated. METHODS For cerebrospinal fluid (CSF) and extracellular space of the brain exchange instantly, we performed a cohort study, applying CSF of SAH patients utilizing different sedatives or no sedation to metabolomics. Baseline CSF metabolome was corrected by selecting patients of the same SAH and agitation severity. CSF components were analyzed to identify the most affected metabolic pathways and sensitive biomarkers of each sedative. Markers might represent the outcome of the patients were also investigated. RESULTS Pentose phosphate pathway was the most significantly interfered (upregulated) pathway in midazolam (p = 0.0000107, impact = 0.35348) and propofol (p = 0.00000000000746, impact = 0.41604) groups. On the contrary, dexmedetomidine decreased levels of sedoheptulose 7-phosphate (p = 0.002) and NADP (p = 0.024), and NADP is the key metabolite and regulator in pentose phosphate pathway. Midazolam additionally augmented purine synthesis (p = 0.00175, impact = 0.13481) and propofol enhanced pyrimidine synthesis (p = 0.000203, impact = 0.20046), whereas dexmedetomidine weakened pyrimidine synthesis (p = 0.000000000594, impact = 0.24922). Reduced guanosine diphosphate (AUC of ROC 0.857, 95%CI 0.617-1, p = 0.00506) was the significant CSF biomarker for midazolam, and uridine diphosphate glucose (AUC of ROC 0.877, 95%CI 0.631-1, p = 0.00980) for propofol, and succinyl-CoA (AUC of ROC 0.923, 95%CI 0.785-1, p = 0.000810) plus adenosine triphosphate (AUC of ROC 0.908, 95%CI 0.6921, p = 0.00315) for dexmedetomidine. Down-regulated CSF succinyl-CoA was also associated with favorable outcome (AUC of ROC 0.708, 95% CI: 0.524-0.865, p = 0.029333). CONCLUSION Pentose phosphate pathway was a crucial target for sedatives which alter brain metabolism. Midazolam and propofol enhanced the pentose phosphate pathway and nucleotide synthesis in poor-grade SAH patients, as presented in the CSF. The situation of dexmedetomidine was the opposite. The divergent modulation of cerebral metabolism might further explain sedative pharmacology and how sedatives affect the outcome of SAH patients.
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Affiliation(s)
- Yi-Chen Li
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
- Department of Neurosurgery, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
- Nanjing Medical Center of Clinical Pharmacy, Nanjing, 210008, China
| | - Rong Wang
- Department of Neurosurgery, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China.
| | - Ji-Ye A
- Key Laboratory of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, 210009, China
| | - Run-Bin Sun
- Key Laboratory of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, 210009, China
| | - Shi-Jie Na
- Department of Neurosurgery, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
| | - Tao Liu
- Department of Neurosurgery, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
| | - Xuan-Sheng Ding
- Department of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Wei-Hong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China
- Nanjing Medical Center of Clinical Pharmacy, Nanjing, 210008, China
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Liu T, Zhong S, Zhai Q, Zhang X, Jing H, Li K, Liu S, Han S, Li L, Shi X, Bao Y. Optimal Course of Statins for Patients With Aneurysmal Subarachnoid Hemorrhage: Is Longer Treatment Better? A Meta-Analysis of Randomized Controlled Trials. Front Neurosci 2021; 15:757505. [PMID: 34759796 PMCID: PMC8573116 DOI: 10.3389/fnins.2021.757505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/20/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Tao Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shiyu Zhong
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 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
| | - Shuo Han
- 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
| | - Xin Shi
- School of Maths and Information Science, Shandong Institute of Business and Technology, Yantai, China.,Business School, Manchester Metropolitan University, Manchester, United Kingdom
| | - Yijun Bao
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
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Cenik Y, Baydin A, Çakmak E, Fidan M, Aydin K, Tuncel ÖK, Aslan K. The Effect of Biomarkers and Optic Nerve Sheath Diameter in Determining Mortality in non-Traumatic Subarachnoid Hemorrhage. Clin Neurol Neurosurg 2021; 207:106813. [PMID: 34311386 DOI: 10.1016/j.clineuro.2021.106813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
AIM Although radiological methods are sufficient for the diagnosis of spontaneous subarachnoid hemorrhage (SAH), additional biomarkers are needed to predict prognosis. The aim of this study was to investigate the effects of serum S100B protein, Glial Fibrillary Acidic Protein (GFAP) levels and, Optic Nerve Sheath Diameter (ONSD) on mortality and clinical severity in patients with spontaneous SAH. MATERIALS AND METHODS Fifty-six patients who were diagnosed with SAH after first evaluation in the emergency department (ED) were included in the study group; Forty-six patients who were admitted to the ED with headache of non-intracranial etiology, were included as the control group. Cerebral computed tomography (CT) images and peripheral blood samples were obtained from all patients; at the time of diagnosis and 24 h after diagnosis. Serum S100B protein and GFAP levels were measured from the blood samples and ONSD was measured on CT. RESULTS Serum S100B protein and GFAP levels and, ONSDs at the time of diagnosis and 24 h after diagnosis were significantly higher in the study group (p < 0.05). Both GFAP levels and ONSD at the time of diagnosis and 24 h after the diagnosis were found to be related with increased mortality (p < 0.05). A similar association was found for serum S100B protein levels 24 h after the diagnosis, but not at the time of diagnosis (p = 0.540). CONCLUSION Serum S100B protein and GFAP levels and, ONSD were increased in patients with spontaneous SAH. All parameters were found to be associated with increased mortality.
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Affiliation(s)
- Yavuz Cenik
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, 55139 Samsun, Turkey
| | - Ahmet Baydin
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, 55139 Samsun, Turkey.
| | - Eser Çakmak
- Department of Medical Biochemistry, Faculty of Medicine, Ondokuz Mayis University, 55139 Samsun, Turkey
| | - Murat Fidan
- Department of Radiology, Faculty of Medicine, Ondokuz Mayis University, 55139 Samsun, Turkey
| | - Keramettin Aydin
- Department of Neurosurgery, Faculty of Medicine, Ondokuz Mayis University, 55139 Samsun, Turkey
| | - Özgür Korhan Tuncel
- Department of Medical Biochemistry, Faculty of Medicine, Ondokuz Mayis University, 55139 Samsun, Turkey
| | - Kerim Aslan
- Department of Radiology, Faculty of Medicine, Ondokuz Mayis University, 55139 Samsun, Turkey
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13
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Clinical condition of 120 patients alive at 3 years after poor-grade aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2021; 163:1153-1166. [PMID: 33629124 PMCID: PMC7904392 DOI: 10.1007/s00701-021-04725-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Abstract
Background To study the clinical condition of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients alive at 3 years after neurointensive care. Methods Of the 769 consecutive aSAH patients from a defined population (2005–2015), 269 (35%) were in poor condition on admission: 145 (54%) with H&H 4 and 124 (46%) with H&H 5. Their clinical lifelines were re-constructed from the Kuopio Intracranial Aneurysm Database and Finnish nationwide registries. Of the 269 patients, 155 (58%) were alive at 14 days, 125 (46%) at 12 months, and 120 (45%) at 3 years. Results The 120 H&H 4–5 patients alive at 3 years form the final study population. On admission, 73% had H&H 4 but only 27% H&H 5, 59% intracerebral hematoma (ICH; median 22 cm3), and 26% intraventricular blood clot (IVH). The outcome was favorable (mRS 0–1) in 45% (54 patients: ICH 44%; IVH clot 31%; shunt 46%), moderate (mRS 2–3) in 30% (36 patients: ICH 64%; IVH clot 19%; shunt 42%), and unfavorable (mRS 4–5) in 25% (30 patients: ICH 80%; IVH clot 23%; shunt 50%). A total of 46% carried a ventriculoperitoneal shunt. ICH volume was a significant predictor of mRS at 3 years. Conclusions Of poor-grade aSAH patients, 45% were alive at 3 years, even 27% of those extending to pain (H&H 5). Of the survivors, 75% were at least in moderate condition, while only 2.6% ended in hospice care. Consequently, we propose non-selected admission to neurointensive care (1) for a possibility of moderate outcome, and (2), in case of brain death, possibly improved organ donation rates.
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Findings Predictive of Poor Outcome in Grade 5 Subarachnoid Hemorrhage: A Cohort Study. Can J Neurol Sci 2021; 48:807-816. [PMID: 33472716 DOI: 10.1017/cjn.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most patients with World Federation of Neurological Surgeons (WFNS) grade 5 subarachnoid hemorrhage (SAH) have poor outcomes. Accurate assessment of prognosis is important for treatment decisions and conversations with families regarding goals of care. Unjustified pessimism may lead to "self-fulfilling prophecy," where withdrawal of life-sustaining measures (WLSM) is invariably followed by death. METHODS We performed a cohort study involving consecutive patients with WFNS grade 5 SAH to identify variables with >= 90% and >= 95% positive predictive value (PPV) for poor outcome (1-year modified Rankin Score >= 4), as well as findings predictive of WLSM. RESULTS Of 140 patients, 38 (27%) had favorable outcomes. Predictors with >= 95% PPV for poor outcome included unconfounded 72-hour Glasgow Coma Scale motor score <= 4, absence of >= 1 pupillary light reflex (PLR) at 24 hours, and intraventricular hemorrhage (IVH) score of >= 20 (volume >= 54.6 ml). Intracerebral hemorrhage (ICH) volume >= 53 ml had PPV of 92%. Variables associated with WLSM decisions included a poor motor score (p < 0.0001) and radiographic evidence of infarction (p = 0.02). CONCLUSIONS We identified several early predictors with high PPV for poor outcome. Of these, lack of improvement in motor score during the initial 72 hours had the greatest potential for confounding from "self-fulfilling prophecy." Absence of PLR at 24 hours, IVH score >= 20, and ICH volume >= 53 ml predicted poor outcome without a statistically significant effect on WLSM decisions. More research is needed to validate prognostic variables in grade 5 SAH, especially among patients who do not undergo WLSM.
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Tasiou A, Brotis AG, Paschalis T, Tzerefos C, Kapsalaki EZ, Giannis T, Tzannis A, Fountas KN. Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience. Int J Neurosci 2020; 132:38-50. [PMID: 32746674 DOI: 10.1080/00207454.2020.1801676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping. MATERIAL AND METHODS In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors. RESULTS Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15th and the 60th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival. CONCLUSIONS Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.
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Affiliation(s)
- Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros G Brotis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Thanasis Paschalis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Eftychia Z Kapsalaki
- Department of Neuroradiology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Theofanis Giannis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alkiviadis Tzannis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
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