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Mistry AM, Naidugari J, Meyer KS, Chen CJ, Williams BJ, Morton RP, Abecassis IJ, Ding D. Partial coil embolization before surgical clipping of ruptured intracranial aneurysms. Acta Neurochir (Wien) 2024; 166:293. [PMID: 38985334 DOI: 10.1007/s00701-024-06186-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 07/02/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE Intraoperative rupture (IOR) is the most common adverse event encountered during surgical clip obliteration of ruptured intracranial aneurysms. Besides increasing surgeon experience and early proximal control, no methods exist to decrease IOR risk. Thus, our objective was to assess if partial endovascular coil embolization to protect the aneurysm before clipping decreases IOR. METHODS We conducted a retrospective analysis of patients with ruptured intracranial aneurysms that were treated with surgical clipping at two tertiary academic centers. We compared patient characteristics and outcomes of those who underwent partial endovascular coil embolization to protect the aneurysm before clipping to those who did not. The primary outcome was IOR. Secondary outcomes were inpatient mortality and discharge destination. RESULTS We analyzed 100 patients. Partial endovascular aneurysm protection was performed in 27 patients. Age, sex, subarachnoid hemorrhage severity, and aneurysm location were similar between the partially-embolized and non-embolized groups. The median size of the partially-embolized aneurysms was larger (7.0 mm [interquartile range 5.95-8.7] vs. 4.6 mm [3.3-6.0]; P < 0.001). During surgical clipping, IOR occurred less frequently in the partially-embolized aneurysms than non-embolized aneurysms (2/27, 7.4%, vs. 30/73, 41%; P = 0.001). Inpatient mortality was 14.8% (4/27) in patients with partially-embolized aneurysms and 28.8% (21/73) in patients without embolization (P = 0.20). Discharge to home or inpatient rehabilitation was 74.0% in patients with partially-embolized aneurysms and 56.2% in patients without embolization (P = 0.11). A complication from partial embolization occurred in 2/27 (7.4%) patients. CONCLUSIONS Preoperative partial endovascular coil embolization of ruptured aneurysms is associated with a reduced frequency of IOR during definitive treatment with surgical clip obliteration. These results and the impact of preoperative partial endovascular coil embolization on functional outcomes should be confirmed with a randomized trial.
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Affiliation(s)
- Akshitkumar M Mistry
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA.
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Kimberly S Meyer
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center, Houston, TX, USA
| | - Brian J Williams
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Ryan P Morton
- Division of Neurosurgery, Brooke Army Medical Center, San Antonio, TX, USA
| | - Isaac J Abecassis
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
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Subah G, Patel R, Nolan B, Fortunato M, Lui A, Uddin A, Li A, Spirollari E, Nuoaman H, Adnan YA, Thomas A, Brill S, Pak I, Ng C, Hecht L, Bauerschmidt A, Mayer S, Gandhi CD, Al-Mufti F. Acute Kidney Injury in Subarachnoid Hemorrhage: Exploring its Clinical Significance and Prognostic Implications. J Stroke Cerebrovasc Dis 2024:107843. [PMID: 38964524 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/06/2024] Open
Abstract
OBJECTIVES Subarachnoid hemorrhage (SAH) from spontaneous rupture of an aneurysm is a debilitating condition with high morbidity and mortality. Patients with SAH remain understudied, particularly concerning the evaluation of incidence and consequences of subsequent acute kidney injury (AKI). In this study, we aim to explore the risk factors and outcomes of AKI in patients with SAH. MATERIALS AND METHODS International Classification of Diseases, 9th Edition and 10th Edition (ICD-10-CM) codes were used to query the National Inpatient Sample (NIS) for patients with a diagnosis of SAH between 2010-2019. Subgroup analysis was stratified by AKI diagnosis during the same hospitalization. AKI and non-AKI groups were assessed for baseline clinical characteristics, interventions, complications, and outcomes. Descriptive statistics, multivariate regressions, and propensity score-matching were performed using IBM SPSS 28. NEED TO MENTION NIH-SSS RESULTS Of 76,553 patients diagnosed with nontraumatic SAH between 2010-2019, 10,634 (13.89%) had a comorbid diagnosis of AKI. Patients with AKI were older (p<0.01) and more often obese (p < 0.01), compared to the non-AKI group. A multivariate regression found the diagnosis of AKI to be independently correlated with poor functional outcome (p<0.001), above average length of stay (p < 0.001), and in-hospital mortality (p < 0.001) when controlling for age, SAH severity, and other comorbidities. CONCLUSIONS This study showed significant association between AKI and adverse outcomes in SAH patients, and a correlation between AKI and heightened complication rates, poor functional outcome, extended hospital stays, and elevated mortality rates. Early detection of AKI in SAH patients is vital to enhance their chances of recovery.
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Affiliation(s)
| | - Rohan Patel
- New York Medical College, Valhalla, NY, USA.
| | | | | | - Aiden Lui
- New York Medical College, Valhalla, NY, USA.
| | - Anaz Uddin
- New York Medical College, Valhalla, NY, USA.
| | - Austin Li
- New York Medical College, Valhalla, NY, USA.
| | | | - Halla Nuoaman
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA.
| | - Yasir Ammar Adnan
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA.
| | - Anish Thomas
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA.
| | - Stuart Brill
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA.
| | - Isaac Pak
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA.
| | - Christina Ng
- Department of Neurosurgery, The University of Vermont Medical Center, Burlington, VT, USA.
| | - Lee Hecht
- Department of Neurology, Downstate Medical Center, Brooklyn, NY, USA.
| | - Andrew Bauerschmidt
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA.
| | - Stephan Mayer
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA.
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA; Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.
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Wang MD, Fu QH, Ni A, Yuan YP, Li CH, Wang ZX, Wang H. The role of early cerebral edema and hematoma assessment in aneurysmal subarachnoid hemorrhage (a-SAH) in predicting early brain injury (EBI) and cognitive impairment: a case controlled study. Int J Surg 2024; 110:3166-3177. [PMID: 38445521 PMCID: PMC11175797 DOI: 10.1097/js9.0000000000001244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/19/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Early assessment and management of cerebral edema and hematoma following aneurysmal subarachnoid hemorrhage (a-SAH) can significantly impact clinical cognitive outcomes. However, current clinical practices lack predictive models to identify early structural brain abnormalities affecting cognition. To address this gap, the authors propose the development of a predictive model termed the a-SAH Early Brain Edema/Hematoma Compression Neural (Structural Brain) Networks Score System (SEBE-HCNNSS). METHODS In this study, 202 consecutive patients with spontaneous a-SAH underwent initial computed tomography (CT) or MRI scans within 24 h of ictus with follow-up 2 months after discharge. Using logistic regression analysis (univariate and multivariate), the authors evaluated the association of clinically relevant factors and various traditional scale ratings with cognitive impairment (CI). Risk factors with the highest area under the curve (AUC) values were included in the multivariate analysis and least absolute shrinkage and selection operator (LASSO) analysis or Cox regression analysis. RESULTS A total of 177 patients were enrolled in the study, and 43 patients were classified with a high SEBE-HCNNSS grade (3-5). After a mean follow-up of 2 months, 121 individuals (68.36%) with a-SAH and three control subjects developed incident CI. The CT interobserver reliability of the SEBE-HCNNSS scale was high, with a Kappa value of 1. Furthermore, ROC analysis identified the SEBE-HCNNSS scale (OR 3.322, 95% CI: 2.312-7.237, P =0.00025) as an independent predictor of edema, CI, and unfavorable prognosis. These results were also replicated in a validation cohort. CONCLUSION Overall, the SEBE-HCNNSS scale represents a simple assessment tool with promising predictive value for CI and clinical outcomes post-a-SAH. Our findings indicate its practical utility as a prognostic instrument for risk evaluation after a-SAH, potentially facilitating early intervention and treatment.
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Affiliation(s)
- Ming-Dong Wang
- Department of Neurosurgery, The First Hospital of Hebei Medical University
- Department of Neurosurgery, Hebei Hospital of Xuanwu Hospital Capital Medical University
| | - Qian-Hui Fu
- College of Pharmacy, MINZU University of China, Key Laboratory of Ministry of Education, Ministry of Education (MINZU University of China), Beijing
| | - Andrew Ni
- Warren Alpert Medical School, Brown University, Providence, USA
| | - Yun-Peng Yuan
- Department of Neurosurgery, Shanghai Baoshan Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai
| | - Chun-Hui Li
- Department of Neurosurgery, The First Hospital of Hebei Medical University
- Department of Neurosurgery, Hebei Hospital of Xuanwu Hospital Capital Medical University
| | - Zhan-Xiang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, People’s Republic of China
| | - Hong Wang
- Department of Neurosurgery, The Affiliated Hospital of Hebei University, Baoding, Hebei
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Mistry AM, Naidugari J, Feldman MJ, Magarik JA, Ding D, Abecassis IJ, Semler MW, Rice TW. Impact of fludrocortisone on the outcomes of subarachnoid hemorrhage patients: A retrospective analysis. J Stroke Cerebrovasc Dis 2024; 33:107643. [PMID: 38387759 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107643] [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: 08/31/2023] [Revised: 02/05/2024] [Accepted: 02/18/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Whether the use of fludrocortisone affects outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS We conducted a retrospective analysis of 78 consecutive patients with a ruptured aSAH at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days. The primary outcome was adjusted for age, hypertension, aSAH grade, and time from aSAH onset to aneurysm treatment. Secondary outcomes were neurologic and cardiopulmonary dysfunction events. RESULTS Among 78 patients at a single center, the median age was 58 years [IQR, 49 to 64.5]; 64 % were female, and 41 (53 %) received fludrocortisone. The adjusted common odds ratio, aOR, of a proportional odds regression model of fludrocortisone use with mRS was 0.33 (95 % CI, 0.14-0.80; P = 0.02), with values <1.0 favoring fludrocortisone. Organ-specific dysfunction events were not statistically different: delayed cerebral ischemia (22 % vs. 39 %, P = 0.16); cardiac dysfunction (0 % vs. 11 %; P = 0.10); and pulmonary edema (15 % vs. 8 %; P = 0.59). CONCLUSIONS The risk of disability or death at 90 days was lower with the use of fludrocortisone in aSAH patients.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Michael J Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jordan A Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Isaac J Abecassis
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Aladawi M, Elfil M, Najdawi ZR, Ghaith H, Sayles H, Thorell W, Hawkes MA. Aneurysmal Subdural Hematoma: A Systematic Review. Neurocrit Care 2024:10.1007/s12028-024-01938-y. [PMID: 38332336 DOI: 10.1007/s12028-024-01938-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 01/03/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Aneurysmal subdural hematoma (aSDH) is a rare complication of aneurysm rupture, affecting between 0.5 and 7.9% of patients with aneurysmal subarachnoid hemorrhage (aSAH). The clinical presentation, course, and outcomes of these patients are largely unknown. OBJECTIVE This study aims to systematically review the literature to evaluate the demographics, clinical presentation, aneurysm location, treatment options, and outcomes of patients with aSDH with and without aSAH. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review of three databases (PubMed, EMBASE, and Google Scholar). From identified reports, we extracted data on patients' demographics, clinical presentation, imaging findings, surgical interventions, and clinical outcomes. We compared clinical outcomes, need for surgical treatment, and aneurysm location between patients with aSDH with and without concurrent aSAH using χ2 and Fisher's exact tests. We used simple and multivariable logistic regression models to further examine the association between the presence of aSAH and surgical treatment with clinical outcomes. RESULTS We identified 112 articles with a total of 270 patients (70% women, mean age 52.8 [± 15.5] years). The most common aneurysm locations were the middle cerebral artery, followed by the posterior communicating artery, and the internal carotid artery. Patients with isolated aSDH fully recovered more frequently than those with concomitant aSAH (38% vs. 6%). The presence of aSAH increased the odds of unfavorable outcome (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.34-5.37). Surgical treatment was inversely associated with unfavorable outcome in the univariable (OR 0.48, 95% CI 0.28-0.84) but not in the multivariable analysis (OR 0.76, 95% CI 0.35-1.66). CONCLUSION aSDH occurs infrequently. Simultaneous presence of both aSDH and aSAH from an aneurysmal source is associated with poor outcomes. Surgical treatment is associated with lower rates of unfavorable outcomes including death and severe disability.
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Affiliation(s)
- Mohammad Aladawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Zaid R Najdawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Hazem Ghaith
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - William Thorell
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maximiliano A Hawkes
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA.
- Department of Neurology, Mayo Clinic, 200 1st ST SW, Rochester, MN, 55905, USA.
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Hofmann BB, Gundlach EP, Fischer I, Muhammad S, Kram R, Beseoglu K, Cornelius JF. Evaluation of FRESH scores in predicting outcome and quality of life after aneurysmal subarachnoid haemorrhage in a European patient cohort. Acta Neurochir (Wien) 2024; 166:29. [PMID: 38261024 PMCID: PMC10806023 DOI: 10.1007/s00701-024-05909-2] [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: 07/13/2023] [Accepted: 11/14/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Despite aneurysmal subarachnoid haemorrhage (aSAH) patients often experiencing physical and mental disabilities impacting their quality of life (QoL), routine assessment of long-term QoL data and predictive tools are limited. This study evaluates the newly developed "functional recovery expected after subarachnoid haemorrhage" (FRESH) scores with long-term outcomes and QoL in European aSAH patients. METHODS FRESH, FRESH-cog, and FRESH-quol scores were retrospectively obtained from aSAH patients. Patients were contacted, and the modified Rankin Scale (mRS), extended short form-36 (SF-36), and telephone interview for cognitive status (TICS) were collected and performed. The prognostic and empirical outcomes were compared. RESULTS Out of 374 patients, 171 patients (54.1%) completed the SF-36, and 154 patients completed the TICS. The SF-36 analysis showed that 32.7% had below-average physical component summary (PCS) scores, and 39.8% had below-average mental component summary (MCS) scores. There was no significant correlation between the FRESH score and PCS (p = 0.09736), MCS (p = 0.1796), TICS (p = 0.7484), or mRS 10-82 months (average 46 months) post bleeding (p = 0.024), respectively. There was also no significant correlation found for "FRESH-cog vs. TICS" (p = 0.0311), "FRESH-quol vs. PCS" (p = 0.0204), "FRESH-quol vs. MCS" (p = 0.1361) and "FRESH-quol vs. TICS" (p = 0.1608). CONCLUSIONS This study found no correlation between FRESH scores and validated QoL tools in a European population of aSAH patients. The study highlights the complexity of reliable long-term QoL prognostication in aSAH patients and emphasises the need for further prospective research to also focus on QoL as an important outcome parameter.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Evgenia P Gundlach
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Rainer Kram
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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Mistry AM, Naidugari J, Craven J, Williams L, Beall J, Khatri P, Broderick JP, Rice TW, Kamel H, Mack W. Usage of mineralocorticoids and isotonic crystalloids in subarachnoid hemorrhage patients in the United States. J Stroke Cerebrovasc Dis 2024; 33:107449. [PMID: 37995500 PMCID: PMC10841607 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107449] [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: 09/04/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. METHODS We surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites in 2023, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters from 2010 to 2020 in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20 % of all acute inpatient care in the United States. RESULTS Although mineralocorticoids are used by 70 % of the NINDS StrokeNet sites, it is used in less than 20 % of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41 and 45 %, respectively. CONCLUSIONS The use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.
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Affiliation(s)
- Akshitkumar M Mistry
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, 15th Floor, Louisville, KY 40202, USA.
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jocelyn Craven
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Logan Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Joseph P Broderick
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Wang H, Bothe TL, Deng C, Lv S, Khedkar PH, Kovacs R, Patzak A, Wu L. Comparison of Prognostic Models for Functional Outcome in Aneurysmal Subarachnoid Hemorrhage Based on Machine Learning. World Neurosurg 2023; 180:e686-e699. [PMID: 37821029 DOI: 10.1016/j.wneu.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Controversy exists regarding the superiority of the performance of prognostic tools based on advanced machine learning (ML) algorithms for patients with aneurysmal subarachnoid hemorrhage (aSAH). However, it is unclear whether ML prognostic models will benefit patients due to the lack of a comprehensive assessment. We aimed to develop and evaluate ML models for predicting unfavorable functional outcomes for aSAH patients and identify the model with the greatest performance. METHODS In this retrospective study, a dataset of 955 patients with aSAH was used to construct and validate prognostic models for functional outcomes assessed using the modified Rankin scale during a follow-up period of 3-6 months. Clinical scores and clinical and radiological features on admission and secondary complications were used to construct models based on 5 ML algorithms (i.e., logistic regression [LR], k-nearest neighbor, extreme gradient boosting, random forest, and artificial neural network). For evaluation among the models, the area under the receiver operating characteristic curve, area under the precision-recall curve, calibration curve, and decision curve analysis were used. RESULTS Composite models had significantly higher area under the receiver operating characteristic curves than did simple models in predicting unfavorable functional outcomes. Compared with other composite models (random forest and extreme gradient boosting) with good calibration, LR had the highest area under the precision-recall score and showed the greatest benefit in decision curve analysis. CONCLUSIONS Of the 5 studied ML models, the conventional LR model outperformed the advanced algorithms in predicting the prognosis and could be a useful tool for health care professionals.
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Affiliation(s)
- Han Wang
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany; Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Tomas L Bothe
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Chulei Deng
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Shengyin Lv
- Department of Neurology, Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Pratik H Khedkar
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Richard Kovacs
- Institute of Neurophysiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Andreas Patzak
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Lingyun Wu
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
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Mistry AM, Naidugari J, Feldman MJ, Magarik JA, Ding D, Abecassis IJ, Semler MW, Rice TW. Impact of Fludrocortisone on the Outcomes of Subarachnoid Hemorrhage Patients: A Retrospective Analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296246. [PMID: 37808869 PMCID: PMC10557818 DOI: 10.1101/2023.09.28.23296246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background Whether the use of fludrocortisone affects outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) and its usage rate in the United States remain unknown. Methods We conducted a retrospective analysis of 78 consecutive patients with a ruptured aSAH at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days. We adjusted the primary outcome for age, hypertension, aSAH grade, and time from aSAH onset to aneurysm treatment. Secondary outcomes were brain and cardiopulmonary dysfunction events. Results Among 78 patients at a single center, the median age was 58 years [IQR, 49 to 64.5]; 64% were female, and 41 (53%) received fludrocortisone. The adjusted common odds ratio, aOR, of a proportional odds regression model of fludrocortisone use with mRS was 0.33 (95% CI, 0.14-0.80; P=0.02), with values <1.0 favoring fludrocortisone. Organ-specific dysfunction events were not statistically different: delayed cerebral ischemia (22% vs. 39%, P=0.16); cardiac dysfunction (0% vs. 11%; P=0.10); and pulmonary edema (15% vs. 8%; P=0.59). Conclusions The risk of disability or death at 90 days was lower with the use of fludrocortisone in aSAH patients.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Michael J. Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jordan A. Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Isaac J. Abecassis
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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Mistry AM, Naidugari J, Craven J, Williams L, Beall J, Khatri P, Broderick JP, Rice TW, Kamel H, Mack W. Usage of Mineralocorticoids and Isotonic Crystalloids in Subarachnoid Hemorrhage Patients in the United States. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296245. [PMID: 37808838 PMCID: PMC10557832 DOI: 10.1101/2023.09.28.23296245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background The usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. Methods We surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20% of all acute inpatient care in the United States. Results Although mineralocorticoids are used by 70% of the NINDS StrokeNet sites in aSAH patients, it is used in less than 25% of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41% and 45%, respectively. Conclusions The use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jocelyn Craven
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Logan Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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11
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Zhou Z, Lu W, Zhang C, Xiang L, Xiang L, Chen C, Wang B, Guo L, Shan Y, Li X, Zhao Z, Zou J, Dai X, Zhao Z. A visualized MAC nomogram online predicts the risk of three-month mortality in Chinese elderly aneurysmal subarachnoid hemorrhage patients undergoing endovascular coiling. Neurol Sci 2023; 44:3209-3220. [PMID: 37020068 PMCID: PMC10075504 DOI: 10.1007/s10072-023-06777-x] [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: 01/21/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is an aggressive disease with higher mortality rate in the elderly population. Unfortunately, the previous models for predicting clinical prognosis are still not accurate enough. Therefore, we aimed to construct and validate a visualized nomogram model to predict online the 3-month mortality in elderly aSAH patients undergoing endovascular coiling. METHOD We conducted a retrospective analysis of 209 elderly aSAH patients at People's Hospital of Hunan Province, China. A nomogram was developed based on multivariate logistic regression and forward stepwise regression analysis, then validated using the bootstrap validation method (n = 1000). In addition, the performance of the nomogram was evaluated by various indicators to prove its clinical value. RESULT Morbid pupillary reflex, age, and using a breathing machine were independent predictors of 3-month mortality. The AUC of the nomogram was 0.901 (95% CI: 0.853-0.950), and the Hosmer-Lemeshow goodness-of-fit test showed good calibration of the nomogram (p = 0.4328). Besides, the bootstrap validation method internally validated the nomogram with an area under the curve of the receiver operator characteristic (AUROC) of 0.896 (95% CI: 0.846-0.945). Decision curve analysis (DCA) and clinical impact curve (CIC) indicated the nomogram's excellent clinical utility and applicability. CONCLUSION An easily applied visualized nomogram model named MAC (morbid pupillary reflex-age-breathing machine) based on three accessible factors has been successfully developed. The MAC nomogram is an accurate and complementary tool to support individualized decision-making and emphasizes that patients with higher risk of mortality may require closer monitoring. Furthermore, a web-based online version of the risk calculator would greatly contribute to the spread of the model in this field.
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Affiliation(s)
- Zhou Zhou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wei Lu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Cheng Zhang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Lan Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Liang Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Chen Chen
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - BiJun Wang
- Clinical Research Institute, Hengyang Medical School, The Affiliated Nanhua Hospital, University of South China, Hengyang, China
| | - LeHeng Guo
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - YaJie Shan
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - XueMei Li
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Zheng Zhao
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - JianJun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China.
| | - XiaoMing Dai
- Department of Hepatobiliary Surgery, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, China.
| | - ZhiHong Zhao
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China.
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12
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Varol E. The Role of Computed Tomographic Angiography in Predicting the Development of Vasospasm Following Ruptured Intracranial Aneurysm Microsurgery. Cureus 2023; 15:e45386. [PMID: 37724099 PMCID: PMC10505260 DOI: 10.7759/cureus.45386] [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] [Accepted: 09/16/2023] [Indexed: 09/20/2023] Open
Abstract
Introduction Following subarachnoid hemorrhage, cerebral vasospasm is the primary cause of morbidity and death. The aim of this study is to predict the development of vasospasm by detecting changes in vessel diameter after surgery using computed tomography angiography. Methods We retrospectively evaluated the patients who underwent aneurysm clipping due to a bleeding aneurysm between 2019-2022. Age, gender, location, subarachnoid hemorrhage grades, development of perioperative rupture, and temporary clip use were examined. Preoperative and postoperative diameters of the internal carotid artery, A1-A2, and M1-M2 were measured. Radiological and clinical vasospasm development in the postoperative period was also documented. Results The aneurysm localizations of the 100 patients (mean age: 50.38±13.04 years) were anterior cerebral artery in 50 patients, internal carotid artery in 37 patients, and middle cerebral artery in 30 patients. In the postoperative follow-up, radiological vasospasm was apparent in 41 patients. The changes in arterial diameter reveal a statistically significant decrease in the internal carotid artery, M1-M2, and A1-A2 artery diameters on the operated side compared to the contralateral side (p<0.001). Based on the receiver operating characteristic (ROC) analysis, the most likely change in arterial diameter on the operated side to indicate the presence of vasospasm was calculated from the available data, where the decrease in total arterial diameter was 13.7%. Conclusion Vasospasm remains one of the significant causes of morbidity and mortality post subarachnoid hemorrhage. While there have been advances in imaging modalities, predicting which patients will develop vasospasm has remained elusive. Our research attempts to provide a quantifiable metric (13.7% decrease in vessel diameter) that can be an early predictor of this complication.
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Affiliation(s)
- Eyüp Varol
- Neurological Surgery, Umraniye Training and Research Hospital, Istanbul, TUR
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13
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Burzyńska M, Uryga A, Woźniak J, Załuski R, Robba C, Goździk W. The Role of Early Serum Biomarkers and Clinical Rating Scales in the Prediction of Delayed Cerebral Ischaemia and Short-Term Outcome after Aneurysmal Subarachnoid Haemorrhage: Single Centre Experience. J Clin Med 2023; 12:5614. [PMID: 37685681 PMCID: PMC10488375 DOI: 10.3390/jcm12175614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Considering the variety of complications that arise after aneurysmal subarachnoid haemorrhage (aSAH) and the complex pathomechanism of delayed cerebral ischaemia (DCI), the task of predicting the outcome assumes a profound complexity. Therefore, there is a need to develop early predictive and decision-making models. This study explores the effect of serum biomarkers and clinical scales on patients' outcomes and their interrelationship with DCI and systemic complications in aSAH. This was a retrospective analysis including aSAH patients admitted to the Wroclaw University Hospital (Wrocław, Poland) from 2011 to 2020. A good outcome was defined as a modified Rankin Scale (mRS) score of 0-2. The prediction of the development of DCI and poor outcome was conducted using logistic regression as a standard model (SM) and random forest as a machine learning method (ML). A cohort of 174 aSAH patients were included in the analysis. DCI was diagnosed in 79 (45%) patients. Significant differences between patients with poor vs. good outcome were determined from their levels of albumin (31 ± 7 vs. 35 ± 5 (g/L); p < 0.001), D-dimer (3.0 ± 4.5 vs. 1.5 ± 2.8 (ng/mL); p < 0.001), procalcitonin (0.2 ± 0.4 vs. 0.1 ± 0.1 (ng/mL); p < 0.001), and glucose (169 ± 69 vs. 137 ± 48 (nmol/L); p < 0.001). SM for DCI prediction included the Apache II scale (odds ratio [OD] 1.05; 95% confidence interval [CI] 1.00-1.09) and albumin level (OD 0.88; CI 0.82-0.95). ML demonstrated that low albumin level, high Apache II scale, increased D-dimer and procalcitonin levels had the highest predictive values for DCI. The integration of clinical parameters and scales with a panel of biomarkers may effectively facilitate the stratification of aSAH patients, identifying those at high risk of secondary complications and poor outcome.
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Affiliation(s)
- Małgorzata Burzyńska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, 50-370 Wroclaw, Poland
| | - Jowita Woźniak
- Department of Neurosurgery, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.W.); (R.Z.)
| | - Rafał Załuski
- Department of Neurosurgery, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.W.); (R.Z.)
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16145 Genoa, Italy
| | - Waldemar Goździk
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
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14
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Weller J, Lampmann T, Asoglu H, Schneider M, Ehrentraut SF, Lehmann F, Güresir E, Dorn F, Petzold GC, Vatter H, Zimmermann J. Additive prognostic impact of the cerebrospinal fluid arginine/ornithine ratio to established clinical scores in aneurysmal subarachnoid hemorrhage. Front Neurol 2023; 14:1156505. [PMID: 37122295 PMCID: PMC10140294 DOI: 10.3389/fneur.2023.1156505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/28/2023] [Indexed: 05/02/2023] Open
Abstract
Cerebrospinal fluid (CSF) metabolites are increasingly recognized as prognostic factors in aneurysmal subarachnoid hemorrhage (SAH). The CSF arginine/ornithine ratio (Arg/Orn) was shown to predict cerebral vasospasms and clinical outcome in SAH. The additive prognostic value of Arg/Orn over established prognostic scores has not been investigated. CSF Arg/Orn and the established prognostic scores SAH, FRESH, SAH-PDS, HAIR, Rosen-McDonald, Hunt and Hess, WFNS and modified Fisher scale were determined in a prospective cohort of patients with aneurysmal SAH. Logistic regression models to predict a favorable outcome, defined as a modified Rankin Scale score of 0-3 at 3 months follow-up, were constructed for each score, both with and without the addition of Arg/Orn. The impact of Arg/Orn was assessed comparing logistic regression models containing the respective score with and without Arg/Orn with the likelihood ratio chi-squared test. CSF Arg/Orn and clinical scores were determined in 38 SAH patients. Arg/Orn was an independent predictor of clinical outcome when added to established prognostic scores (p < 0.05) with the exception of HAIR (p = 0.078). All models were significantly improved if Arg/Orn was added as a covariable (p < 0.05). The results of this study confirm Arg/Orn as an independent prognostic factor and its addition improves established prognostic models in SAH.
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Affiliation(s)
- Johannes Weller
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Tim Lampmann
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Harun Asoglu
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | | | - Felix Lehmann
- Department of Anesthesiology, University Hospital Bonn, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Gabor C. Petzold
- Department of Neurology, University Hospital Bonn, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
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15
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Li R, Lin F, Chen Y, Lu J, Han H, Ma L, Zhao Y, Yan D, Li R, Yang J, He S, Li Z, Zhang H, Yuan K, Wang K, Hao Q, Ye X, Wang H, Li H, Zhang L, Shi G, Zhou J, Zhao Y, Zhang Y, Li Y, Wang S, Chen X, Zhao Y. A 90-Day Prognostic Model Based on the Early Brain Injury Indicators after Aneurysmal Subarachnoid Hemorrhage: the TAPS Score. Transl Stroke Res 2023; 14:200-210. [PMID: 35567655 DOI: 10.1007/s12975-022-01033-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/17/2022] [Accepted: 05/06/2022] [Indexed: 12/11/2022]
Abstract
This study aimed to establish a new scoring model based on the early brain injury (EBI) indicators to predict the 90-day functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). We retrospectively enrolled 825 patients and prospectively enrolled 108 patients with aSAH who underwent surgical clipping or endovascular coiling (derivation cohort = 640; validation cohort = 185; prospective cohort = 108) in our institute. We established a logistic regression model based on independent risk factors associated with 90-day unfavorable outcomes. The discrimination of the prognostic model was assessed by the area under the curve in a receiver operating characteristic curve analysis. The Hosmer-Lemeshow goodness-of-fit test and a calibration plot were used to evaluate the calibration of the prediction model. The developed scoring model named "TAPS" (total score, 0-7 points) included the following admission variables: age > 55 years old, WFNS grade of 4-5, mFS grade of 3-4, Graeb score of 5-12, white blood cell count > 11.28 × 109/L, and surgical clipping. The model showed good discrimination with the area under the curve in the derivation, validation, and prospective cohorts which were 0.816 (p < 0.001, 95%CI = 0.77-0.86), 0.810 (p < 0.001, 95%CI = 0.73-0.90), and 0.803 (p < 0.001, 95%CI = 0.70-0.91), respectively. The model also demonstrated good calibration (Hosmer-Lemeshow goodness-of-fit test: X2 = 1.75, df = 8, p = 0.988). Compared with other predictive models, TAPS is an easy handle tool for predicting the 90-day unfavorable outcomes of aSAH patients, which can help clinicians better understand the concept of EBI and quickly identify those patients at risk of poor prognosis, providing more positive treatment strategies. Trial registration: NCT04785976. Registered 5 March 2021-retrospectively registered, http://www.clinicaltrials.gov .
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Affiliation(s)
- Runting Li
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Fa Lin
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Yu Chen
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Junlin Lu
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Heze Han
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Li Ma
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Yahui Zhao
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Debin Yan
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Ruinan Li
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Jun Yang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Shihao He
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Zhipeng Li
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Haibin Zhang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Kexin Yuan
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Ke Wang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Qiang Hao
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Xun Ye
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Hao Wang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Hongliang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China. .,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| | - Yuanli Zhao
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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16
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Alsbrook DL, Di Napoli M, Bhatia K, Desai M, Hinduja A, Rubinos CA, Mansueto G, Singh P, Domeniconi GG, Ikram A, Sabbagh SY, Divani AA. Pathophysiology of Early Brain Injury and Its Association with Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Review of Current Literature. J Clin Med 2023; 12:jcm12031015. [PMID: 36769660 PMCID: PMC9918117 DOI: 10.3390/jcm12031015] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023] Open
Abstract
Background: Delayed cerebral ischemia (DCI) is a common and serious complication of aneurysmal subarachnoid hemorrhage (aSAH). Though many clinical trials have looked at therapies for DCI and vasospasm in aSAH, along with reducing rebleeding risks, none have led to improving outcomes in this patient population. We present an up-to-date review of the pathophysiology of DCI and its association with early brain injury (EBI). Recent Findings: Recent studies have demonstrated that EBI, as opposed to delayed brain injury, is the main contributor to downstream pathophysiological mechanisms that play a role in the development of DCI. New predictive models, including advanced monitoring and neuroimaging techniques, can help detect EBI and improve the clinical management of aSAH patients. Summary: EBI, the severity of subarachnoid hemorrhage, and physiological/imaging markers can serve as indicators for potential early therapeutics in aSAH. The microcellular milieu and hemodynamic pathomechanisms should remain a focus of researchers and clinicians. With the advancement in understanding the pathophysiology of DCI, we are hopeful that we will make strides toward better outcomes for this unique patient population.
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Affiliation(s)
- Diana L Alsbrook
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, 67039 L'Aquila, Italy
| | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Masoom Desai
- Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Clio A Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences, University of Campania, 80138 Naples, Italy
| | - Puneetpal Singh
- Department of Human Genetics, Punjabi University, Patiala 147002, India
| | - Gustavo G Domeniconi
- Unidad de Cuidados Intensivos, Sanatorio de la Trinidad San Isidro, Buenos Aires 1640, Argentina
| | - Asad Ikram
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
| | - Sara Y Sabbagh
- Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
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17
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The value of comorbidities and illness severity scores as prognostic tools for early outcome estimation in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2022; 45:3829-3838. [PMID: 36367594 PMCID: PMC9663372 DOI: 10.1007/s10143-022-01890-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/24/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular disease not only causing brain injury but also frequently inducing a significant systemic reaction affecting multiple organ systems. In addition to hemorrhage severity, comorbidities and acute extracerebral organ dysfunction may impact the prognosis after aSAH as well. The study objective was to assess the value of illness severity scores for early outcome estimation after aSAH. A retrospective analysis of consecutive aSAH patients treated from 2012 to 2020 was performed. Comorbidities were evaluated applying the Charlson comorbidity index (CCI) and the American Society of Anesthesiologists (ASA) classification. Organ dysfunction was assessed by calculating the simplified acute physiology score (SAPS II) 24 h after admission. Modified Rankin scale (mRS) at 3 months was documented. The outcome discrimination power was evaluated. A total of 315 patients were analyzed. Significant comorbidities (CCI > 3) and physical performance impairment (ASA > 3) were found in 15% and 12% of all patients, respectively. The best outcome discrimination power showed SAPS II (AUC 0.76), whereas ASA (AUC 0.65) and CCI (AUC 0.64) exhibited lower discrimination power. A SAPS II cutoff of 40 could reliably discriminate patients with good (mRS ≤ 3) from those with poor outcome (p < 0.0001). Calculation of SAPS II allowed a comprehensive depiction of acute organ dysfunctions and facilitated a reliable early prognosis estimation in our study. In direct comparison to CCI and ASA, SAPS II demonstrated the highest discrimination power and deserves a consideration as a prognostic tool after aSAH.
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18
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Zhang GG, Hao JH, Yong Q, Nie QQ, Yuan GQ, Zheng ZQ, Li JQ. Lactate-to-albumin ratio is associated with in-hospital mortality in patients with spontaneous subarachnoid hemorrhage and a nomogram model construction. Front Neurol 2022; 13:1009253. [PMID: 36324387 PMCID: PMC9618723 DOI: 10.3389/fneur.2022.1009253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/23/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Subarachnoid hemorrhage (SAH) is a severe hemorrhagic stroke with high mortality. However, there is a lack of clinical tools for predicting in-hospital mortality in clinical practice. LAR is a novel clinical marker that has demonstrated prognostic significance in a variety of diseases. Methods Critically ill patients diagnosed and SAH with their data in the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and the eICU Collaborative Research Database (eICU-CRD) were included in our study. Multivariate logistic regression was utilized to establish the nomogram. Results A total of 244 patients with spontaneous SAH in the MIMIC-IV database were eligible for the study as a training set, and 83 patients in eICU-CRD were included for external validation. Data on clinical characteristics, laboratory parameters and outcomes were collected. Univariate and multivariate logistic regression analysis identified age (OR: 1.042, P-value: 0.003), LAR (OR: 2.592, P-value: 0.011), anion gap (OR: 1.134, P-value: 0.036) and APSIII (OR: 1.028, P-value: < 0.001) as independent predictors of in-hospital mortality and we developed a nomogram model based on these factors. The nomogram model incorporated with LAR, APSIII, age and anion gap demonstrated great discrimination and clinical utility both in the training set (accuracy: 77.5%, AUC: 0.811) and validation set (accuracy: 75.9%, AUC: 0.822). Conclusion LAR is closely associated with increased in-hospital mortality of patients with spontaneous SAH, which could serve as a novel clinical marker. The nomogram model combined with LAR, APSIII, age, and anion gap presents good predictive performance and clinical practicability.
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Affiliation(s)
- Guo-Guo Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jia-Hui Hao
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qi Yong
- Department of Internal Medicine, The Seventh Affiliated Hospital of University of South of China, Changsha, China
| | - Qian-Qian Nie
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Gui-Qiang Yuan
- Department of Neurosurgery, Changshu No.2 People's Hospital, Changshu, China
| | - Zong-Qing Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Jin-Quan Li
| | - Jin-Quan Li
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Zong-Qing Zheng
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Mistry AM, Magarik JA, Feldman MJ, Wang L, Lindsell CJ, Fusco MR, Chitale RV, Bernard GR, Self WH, Rice TW, Hughes CG, Mistry EA, Semler MW. Saline versus Balanced Crystalloids for Adults with Aneurysmal Subarachnoid Hemorrhage: A Subgroup Analysis of the SMART Trial. STROKE (HOBOKEN, N.J.) 2022; 2:e000128. [PMID: 36186896 PMCID: PMC9518828 DOI: 10.1161/svin.121.000128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Whether the composition of intravenous crystalloid solutions affects outcomes in adults with aneurysmal subarachnoid hemorrhage (aSAH) remains unknown. Therefore, we determined whether the use of saline is associated with lower risk of disability and death in aSAH patients compared to balanced crystalloids. METHODS We conducted a post hoc subgroup analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), a pragmatic, unblinded, cluster-randomized, multiple-crossover clinical trial that enrolled 15,802 adults between June 2015 and April 2017. We compared intravenous administration of saline to balanced crystalloids in consecutively enrolled aSAH patients aged 18 years or older whose ruptured aneurysm was procedurally secured at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days obtained from a prospective institutional stroke registry. Secondary outcome included death by 90 days. Logistic or proportional odds regression models were used to test for between-group differences adjusted for age, hypertension, aSAH grade, and procedure type. RESULTS Of the 79 aSAH patients procedurally treated during the SMART study period, 78 were enrolled (median age, 58 years; IQR, 49 to 64.5; 64% female), with 41 (53%) assigned to saline and 37 (47%) to balanced crystalloids. Plasma-Lyte was the primary balanced crystalloid used. Among 72 patients with 90-day mRS assessment, the adjusted common odds ratio, aOR, for mRS was 0.68 (95% CI, 0.28-1.63; P=0.39), with values less than 1.0 favoring saline. By 90 days, 2/39 patients (5%) in the saline group and 9/35 (26%) in the balanced-crystalloids group had died (aOR, 0.06; 95% CI, 0.00-0.50; P=0.02). CONCLUSIONS Among procedurally treated aSAH patients, the risk of disability or death at 90 days did not significantly differ between saline and balanced crystalloids. Death occurred less frequently with saline than balanced crystalloids.
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Affiliation(s)
| | - Jordan A. Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J. Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Matthew R. Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rohan V. Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gordon R. Bernard
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G. Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eva A. Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Aitkulova A, Mukhtarova K, Zholdybayeva E, Medetov Y, Dzhamantayeva B, Kassymbek K, Utupov T, Akhmetollayev I, Akshulakov S, Kulmambetova G, Ramankulov Y. Activated leukocyte cell adhesion molecule/cluster of differentiation 166 rs10933819 (G>A) variant is associated with familial intracranial aneurysms. Biomed Rep 2022; 17:65. [PMID: 35815187 PMCID: PMC9260160 DOI: 10.3892/br.2022.1548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/01/2022] [Indexed: 11/06/2022] Open
Abstract
Rupture of intracranial aneurysms (IAs) is the most common cause of subarachnoid hemorrhage (SAH). Currently, there is sufficient evidence to indicate that inflammatory responses contribute to aneurysm rupture. Moreover, the familial occurrence of SAH suggests that genetic factors may be involved in disease susceptibility. In the present study, a clinically proven case of IA in a patient who is a heterozygous mutation carrier of the activated leukocyte cell adhesion molecule (ALCAM)/cluster of differentiation 166 (CD166) gene, is reported. Genomic DNA was extracted from two siblings diagnosed with SAH and other available family members. A variant prioritization strategy that focused on functional prediction, frequency, predicted pathogenicity, and segregation within the family was employed. Sanger sequencing was also performed on the unaffected relatives to assess the segregation of variants within the phenotype. The verified mutations were sequenced in 145 ethnicity-matched healthy individuals. Based on whole exome sequencing data obtained from three individuals, two of whom were diagnosed with IAs, the single-nucleotide variant rs10933819 was prioritized in the family. Only one variant, rs10933819 (G>A), in ALCAM co-segregated with the phenotype, and this mutation was absent in ethnicity-matched healthy individuals. Collectively, ALCAM c1382 G>A p.Gly229Val was identified, for the first time, as a pathogenic mutation in this IA pedigree.
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Affiliation(s)
- Akbota Aitkulova
- National Center for Biotechnology, Nur Sultan 010000, Republic of Kazakhstan
| | - Kymbat Mukhtarova
- National Center for Biotechnology, Nur Sultan 010000, Republic of Kazakhstan
| | - Elena Zholdybayeva
- National Center for Biotechnology, Nur Sultan 010000, Republic of Kazakhstan
| | - Yerkin Medetov
- National Center of Neurosurgery, Nazarbayev University, Nur Sultan 010000, Republic of Kazakhstan
| | - Botagoz Dzhamantayeva
- National Center of Neurosurgery, Nazarbayev University, Nur Sultan 010000, Republic of Kazakhstan
| | - Kuat Kassymbek
- National Center for Biotechnology, Nur Sultan 010000, Republic of Kazakhstan
| | - Talgat Utupov
- National Center for Biotechnology, Nur Sultan 010000, Republic of Kazakhstan
| | - Ilyas Akhmetollayev
- National Center for Biotechnology, Nur Sultan 010000, Republic of Kazakhstan
| | - Serik Akshulakov
- National Center of Neurosurgery, Nazarbayev University, Nur Sultan 010000, Republic of Kazakhstan
| | | | - Yerlan Ramankulov
- National Center for Biotechnology, Nur Sultan 010000, Republic of Kazakhstan
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21
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Hathidara MY, Campos Y, Chandrashekhar S, Xu C, Olson DM, Venkatachalam A, Ray B. Scoring system to predict hospital outcome after subarachnoid hemorrhage-incorporating systemic response: The CRIG score. J Stroke Cerebrovasc Dis 2022; 31:106577. [PMID: 35623237 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106577] [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: 03/28/2022] [Revised: 05/08/2022] [Accepted: 05/15/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Local and systemic proinflammatory and prothrombotic processes after aneurysmal subarachnoid hemorrhage (aSAH) precipitate delayed cerebral ischemia (DCI) and determine clinical outcome. Recent studies using admission and temporal trends of mean platelet volume to platelet count ratio (MPV:PLT) and neutrophil to lymphocyte ratio (NLR) have identified patients developing DCI. We examine if MPV:PLT and NLR along with admission clinical or radiological features can be used to develop a scoring system to predict DCI and in-hospital clinical outcome. MATERIALS AND METHODS A 7-year retrospective cohort of aSAH patients admitted to a tertiary care medical center was used to study and identify clinical, radiological and laboratory parameters to predict DCI and clinical outcome (good: discharge to home or rehabilitation facility; poor: all other discharge destinations). Using regression analyses a scoring system (Clinical, Radiological, Inflammatory, dysGlycemia, CRIG) was developed. RESULTS Of 271 patients, admission clinical grade (World Federation of Neurological Surgeons' scale), radiological grade (modified Fisher score), NLR and glycated hemoglobin were identified as contributors for CRIG score. CRIGDCI score threshold of 112 and CRIGdischarge 109, respectively predicted DCI and adverse clinical outcome in score development cohort. The same threshold predicted DCI and adverse clinical outcome with 78.1 and 100% sensitivity, 44.0 and 52.2% specificity, and 63.2 and 61.4% accuracy, respectively in the score validation cohort. CONCLUSIONS CRIG is an easily calculable scoring system that incorporates systemic response of aSAH - thus, alluding to its multisystem nature. It can be used at the time of admission to predict DCI and clinical outcome.
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Affiliation(s)
- Mausaminben Y Hathidara
- Department of Neurology, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Yesica Campos
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd. #8897, Dallas, TX 75390-8897, USA
| | - Swathy Chandrashekhar
- Department of Neurology, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Chao Xu
- Hudson College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - DaiWai M Olson
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd. #8897, Dallas, TX 75390-8897, USA
| | - Aardhra Venkatachalam
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd. #8897, Dallas, TX 75390-8897, USA
| | - Bappaditya Ray
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd. #8897, Dallas, TX 75390-8897, USA.
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22
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Göttsche J, Piffko A, Pantel TF, Westphal M, Dührsen L, Czorlich P, Sauvigny T. Aneurysm Location Affects Clinical Course and Mortality in Patients With Subarachnoid Hemorrhage. Front Neurol 2022; 13:846066. [PMID: 35359650 PMCID: PMC8964037 DOI: 10.3389/fneur.2022.846066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/28/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The influence of preexisting factors on the clinical course of patients with subarachnoid hemorrhage (SAH), such as patient age, arterial hypertension, and aneurysm characteristics, is still a matter of debate. However, the specific impact of the exact aneurysm location has not received adequate attention. Therefore, the aim of this study was to investigate the influence of aneurysm location as a preexisting factor on the clinical course and mortality. Methods The data of consecutive patients with aneurysmal SAH who were treated from October 2010 to July 2020 were retrospectively analyzed. We distinguished four aneurysm locations: the anterior complex, internal carotid artery (ICA), middle cerebral artery (MCA), and posterior circulation. Logistic regression analysis and receiver operating characteristics were used to investigate the influence of aneurysm location on the occurrence of acute hydrocephalus, Delayed Cerebral Ischemia (DCI), neurological outcome, and in-hospital mortality. Neurological outcome was assessed 3 months after discharge using the Glasgow Outcome Scale. Results A total of 603 patients were included in this study. Patients with MCA aneurysms were 2.52 times less likely to develop acute hydrocephalus compared to patients with anterior complex aneurysms (p = 0.001). Delayed cerebral ischemia occurred most frequently in patients with an anterior complex aneurysm and least frequently in MCA aneurysms (p = 0.014). In ICA aneurysms, mortality was 2.56-fold higher than in patients with aneurysms of the anterior complex (p = 0.006). An additional ROC analysis showed a good prediction for in-hospital mortality when taking the aneurysm's location into account [AUC.855 (CI.817 −0.893)]. Conclusions The aneurysm's location proved to be a significant predictor of acute hydrocephalus, DCI, and in-hospital mortality, demonstrating the impact of this preexisting biological factor on the course of SAH.
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Affiliation(s)
- Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias F Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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23
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Al-Mistarehi AH, Elsayed MA, Ibrahim RM, Elzubair TH, Badi S, Ahmed MH, Alkhaddash R, Ali MK, Khader YS, Alomari S. Clinical Outcomes of Primary Subarachnoid Hemorrhage: An Exploratory Cohort Study from Sudan. Neurohospitalist 2022; 12:249-263. [PMID: 35419154 PMCID: PMC8995598 DOI: 10.1177/19418744211068289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Although Subarachnoid Hemorrhage (SAH) is an emergency condition, its epidemiology and prognosis remain poorly understood in Africa. We aim to explore the clinical presentations, outcomes, and potential mortality predictors of primary SAH patients within 3 weeks of hospitalization in a tertiary hospital in Sudan. Methods We prospectively studied 40 SAH patients over 5 months, with 3 weeks of follow-up for the symptomatology, signs, Glasgow coma scale (GCS), CT scan findings, and outcomes. The fatal outcome group was defined as dying within 3 weeks. Results The mean age was 53.5 years (SD, 6.9; range, 41–65), and 62.5% were women. One-third (30.0%) were smokers, 37.5% were hypertensive, two-thirds (62.5%) had elevated blood pressure on admission, 37.5% had >24 hours delayed presentation, and 15% had missed SAH diagnosis. The most common presenting symptoms were headache and neck pain/stiffness, while seizures were reported in 12.5%. Approximately one-quarter of patients (22.5%) had large-sized Computed Tomography scan hemorrhage, and 40.0% had moderate size. In-hospital mortality rate was 40.0% (16/40); and 87.5% of them passed away within the first week. Compared to survivors, fatal outcome patients had significantly higher rates of smoking (50.0%), hypertension (68.8%), elevated presenting blood pressure (93.8%), delayed diagnosis (56.2%), large hemorrhage (56.2%), lower GCS scores at presentation, and cerebral rebleeding ( P < 0.05 for each). The primary causes of death were the direct effect of the primary hemorrhage (43.8%), rebleeding (31.3%), and delayed cerebral infarction (12.5%). Conclusions SAH is associated with a high in-hospital mortality rate in this cohort of Sudanese SAH patients due to modifiable factors such as delayed diagnosis, hypertension, and smoking. Strategies toward minimizing these factors are recommended.
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Affiliation(s)
- Abdel-Hameed Al-Mistarehi
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Muaz A. Elsayed
- Department of Neurology, Faculty of Medicine and Health Sciences, Omdurman Islamic University, Omdurman Teaching Hospital / Sudan Medical Specialization Board, Khartoum, Sudan
| | | | - Tarig Hassan Elzubair
- Department of Psychiatry, Faculty of Medicine, University of Science and Technology (UST), Khartoum, Sudan
| | - Safaa Badi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Omdurman Islamic University, Khartoum, Sudan
| | - Mohamed H. Ahmed
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital, NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire, UK
| | - Raed Alkhaddash
- Department of Neurology, The University of Tennessee Health Science Center (UTHSC), Memphis, TN, USA
| | - Musaab K. Ali
- Department of Emergency Medicine, King Abdullah University Hospital, Irbid, Jordan/Faculty of Medicine and Health Sciences, Omdurman Islamic University, Khartoum, Sudan
| | - Yousef S. Khader
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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24
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Park HG, Kim S, Chung J, Jang CK, Park KY, Lee JW. Intraventricular hemorrhage clot clearance rate as an outcome predictor in patients with aneurysmal subarachnoid hemorrhage: A retrospective study. BMC Neurol 2021; 21:482. [PMID: 34893025 PMCID: PMC8665536 DOI: 10.1186/s12883-021-02505-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/09/2021] [Indexed: 11/24/2022] Open
Abstract
Background The development of intraventricular hemorrhage (IVH) in aneurysmal subarachnoid hemorrhage (aSAH) is linked with higher mortality and poor neurological recovery. Previous studies have investigated the effect of the amount and distribution of the initial IVH on the prognosis of aSAH. However, no studies have assessed the relationship between the changes in IVH over time and the prognosis of aSAH. The aim of this study was to analyze the effect of the clearance rate of IVH, which can be represented by the IVH clot clearance rate (CCR), on the outcomes of aSAH. Methods The IVH CCR was calculated based on the difference between the initial and follow-up modified Graeb scores (mGS), which were assessed by initial and 7-day follow-up brain computed tomography, respectively. Poor functional outcome was defined as a modified Rankin Scale score of 3-6. Univariate and multivariable analyses were performed to assess the relationships between IVH CCR and other risk factors and the prognosis of patients. Receiver operating characteristic curve analysis was performed to identify cut-off values of IVH CCR for predicting poor functional outcome. Results In total, 196 consecutive patients were diagnosed with aSAH between January 2014 and March 2018. According to the inclusion and exclusion criteria, 67 patients were finally included in the study. The univariate analysis revealed that a lower IVH CCR (p<0.001), higher initial mGS (p<0.001), older age (p<0.001), higher initial Hunt and Hess grade (p<0.001), presence of delayed infarction (p=0.03), and presence of shunt-dependent hydrocephalus (p=0.004) were significantly related to poor functional outcome. The multivariable analysis revealed that IVH CCR (odds ratio [OR] 0.941; p=0.029), initial mGS (OR 1.632; p=0.043), age (OR 1.561; p=0.007), initial Hunt and Hess grade (OR 227.296; p=0.030), and delayed infarction (OR 5310.632; p=0.023) were independent predictors of poor functional outcome. Optimal cut-off values of IVH CCR and mGS for poor outcome were 36.27%, and 13.5, respectively (all p< 0.001). Conclusions The IVH CCR might have an important predictive value on poor functional outcome in patients with aSAH and IVH, along with initial mGS, age, initial Hunt and Hess grade, and delayed infarction.
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Affiliation(s)
- Hae Gi Park
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sunghan Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Ki Jang
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Whan Lee
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea.
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25
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Simon-Pimmel J, Foucher Y, Léger M, Feuillet F, Bodet-Contentin L, Cinotti R, Frasca D, Dantan E. Methodological quality of multivariate prognostic models for intracranial haemorrhages in intensive care units: a systematic review. BMJ Open 2021; 11:e047279. [PMID: 34548347 PMCID: PMC8458313 DOI: 10.1136/bmjopen-2020-047279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Patients with severe spontaneous intracranial haemorrhages, managed in intensive care units, face ethical issues regarding the difficulty of anticipating their recovery. Prognostic tools help clinicians in counselling patients and relatives and guide therapeutic decisions. We aimed to methodologically assess prognostic tools for functional outcomes in severe spontaneous intracranial haemorrhages. DATA SOURCES Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations, we conducted a systematic review querying Medline, Embase, Web of Science, and the Cochrane in January 2020. STUDY SELECTION We included development or validation of multivariate prognostic models for severe intracerebral or subarachnoid haemorrhage. DATA EXTRACTION We evaluated the articles following the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies and Transparent Reporting of multivariable prediction model for Individual Prognosis Or Diagnosis statements to assess the tools' methodological reporting. RESULTS Of the 6149 references retrieved, we identified 85 articles eligible. We discarded 43 articles due to the absence of prognostic performance or predictor selection. Among the 42 articles included, 22 did not validate models, 6 developed and validated models and 14 only externally validated models. When adding 11 articles comparing developed models to existing ones, 25 articles externally validated models. We identified methodological pitfalls, notably the lack of adequate validations or insufficient performance levels. We finally retained three scores predicting mortality and unfavourable outcomes: the IntraCerebral Haemorrhages (ICH) score and the max-ICH score for intracerebral haemorrhages, the SubArachnoid Haemorrhage International Trialists score for subarachnoid haemorrhages. CONCLUSIONS Although prognostic studies on intracranial haemorrhages abound in the literature, they lack methodological robustness or show incomplete reporting. Rather than developing new scores, future authors should focus on externally validating and updating existing scores with large and recent cohorts.
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Affiliation(s)
- Jeanne Simon-Pimmel
- UMR 1246 Methods in Patients-Centered Outcomes and Health Research, INSERM, Nantes, France
| | - Yohann Foucher
- UMR 1246 Methods in Patients-Centered Outcomes and Health Research, INSERM, Nantes, France
- Biostatistician, University Hospital Centre Nantes, Nantes, Pays de la Loire, France
| | - Maxime Léger
- UMR 1246 Methods in Patients-Centered Outcomes and Health Research, INSERM, Nantes, France
- Medical Intensive Care, Angers University Hospital, Nantes, France
| | - Fanny Feuillet
- UMR 1246 Methods in Patients-Centered Outcomes and Health Research, INSERM, Nantes, France
- Biostatistics and Methodology Unit, University Hospital Centre Nantes, Nantes, Pays de la Loire, France
| | - Laetitia Bodet-Contentin
- UMR 1246 Methods in Patients-Centered Outcomes and Health Research, INSERM, Nantes, France
- Intensive Care Unit, Regional University Hospital Centre Tours, Tours, Centre, France
| | - Raphaël Cinotti
- Anaesthesia and Intensive Care Unit, Hôpital Laennec, Saint-Herblain, University Hospital of Nantes, France, Université de Nantes, CHU Nantes, Saint-Herblain, France
| | - Denis Frasca
- UMR 1246 Methods in Patients-Centered Outcomes and Health Research, INSERM, Nantes, France
- Anesthesia and Critical Care Department, University Hospital Centre Poitiers, Poitiers, France
| | - Etienne Dantan
- UMR 1246 Methods in Patients-Centered Outcomes and Health Research, INSERM, Nantes, France
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26
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Zhang A, Zhang Z, Zhang WB, Wang X, Lenahan C, Fang Y, Luo Y, Liu Y, Mei S, Chen S, Zhang J. Development of a nomogram for predicting clinical outcome in patients with angiogram-negative subarachnoid hemorrhage. CNS Neurosci Ther 2021; 27:1339-1347. [PMID: 34320688 PMCID: PMC8504520 DOI: 10.1111/cns.13712] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 12/17/2022] Open
Abstract
To the best of our knowledge, this is the largest clinical retrospective study in AN‐SAH patients, and is the first time to establish accurate predictive models paired with bleeding pattern.
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Affiliation(s)
- Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Zeyu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Wen-Bo Zhang
- Department of Neurosurgery, National Clinical Research Center for Child Health, The Children's Hospital of Zhejiang University School of Medicine, Zhejiang, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Cameron Lenahan
- Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA.,Burrell College of Osteopathic Medicine, Las Cruces, NM, USA
| | - Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Yujie Luo
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Shuhao Mei
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
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Said M, Gümüs M, Herten A, Dinger TF, Chihi M, Darkwah Oppong M, Deuschl C, Wrede KH, Kleinschnitz C, Sure U, Jabbarli R. Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) as a radiographic marker of clinically relevant intracranial hypertension and unfavorable outcome after subarachnoid hemorrhage. Eur J Neurol 2021; 28:4051-4059. [PMID: 34293828 DOI: 10.1111/ene.15033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE The severity of early brain edema (EBE) after aneurysm rupture was reported to be strongly associated with the risk of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Using the recently developed Subarachnoid Hemorrhage Early Brain Edema Score (SEBES), we analyzed the predictors of EBE and its impact on complications related to intracranial pressure (ICP) increase after SAH and on poor outcome. METHODS All consecutive SAH cases treated between January 2003 and June 2016 with assessable SEBES were included (n = 745). Data on demographic characteristics, medical history, initial severity of SAH, need for conservative ICP treatment and decompressive craniectomy, occurrence of cerebral infarctions and unfavorable outcome at 6 months (modified Rankin scale score > 2) were collected. Univariable and multivariable analyses were performed. RESULTS Younger age (<55 years; adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI] 2.28-4.38), female sex (aOR 1.64, 95% CI 1.16-2.31), poor initial clinical condition (World Federation of Neurosurgical Societies score 4-5; aOR 1.74, 95% CI 1.23-2.46), presence of intracerebral hemorrhage (aOR 1.63, 95% CI 1.12-2.36), hypothyroidism (aOR 0.60, 95% CI 0.37-0.98) and renal comorbidity (aOR 0.29, 95% CI 0.11-0.78) were independently associated with SEBES (scores 3-4). There was an independent association between SEBES 3-4 and the need for conservative ICP treatment (aOR 2.43, 95% CI 1.73-3.42), decompressive craniectomy (aOR 2.68, 95% CI 1.84-3.89), development of cerebral infarcts (aOR 2.24, 95% CI 1.53-3.29) and unfavorable outcome (aOR 1.48, 95% CI 1.0-2.17). CONCLUSIONS SEBES is a reliable predictor of ICP-related complications and poor outcome of SAH. Our findings highlight the need for further research of the impact of patients' demographic characteristics and comorbidities on the severity of EBE after SAH.
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Affiliation(s)
- Maryam Said
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Meltem Gümüs
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Cornelius Deuschl
- Department of Diagnostic and Interventional Radiology, University Hospital of Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational and Behavioral Neurosciences (C-TNBS), University Hospital of Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
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28
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Comorbidities and Medical Complications in Hospitalized Subarachnoid Hemorrhage Patients. Can J Neurol Sci 2021; 49:569-578. [PMID: 34275514 DOI: 10.1017/cjn.2021.176] [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] [Indexed: 12/17/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) remains a devastating condition with a case fatality of 36% at 30 days. Risk factors for mortality in SAH patients include patient demographics and the severity of the neurological injury. Pre-existing conditions and non-neurological medical complications occurring during the index hospitalization are also risk factors for mortality in SAH. The magnitude of the effect on mortality of pre-existing conditions and medical complications, however, is less well understood. In this study, we aim to determine the effect of pre-existing conditions and medical complications on SAH mortality. METHODS For a 25% random sample of the Greater Montreal Region, we used discharge abstracts, physician billings, and death certificate records, to identify adult patients with a new diagnosis of non-traumatic SAH who underwent cerebral angiography or surgical clipping of an aneurysm between 1997 and 2014. RESULTS The one-year mortality rate was 14.76% (94/637). Having ≥3 pre-existing conditions was associated with increased one-year mortality OR 3.74, 95% CI [1.25, 9.57]. Having 2, or ≥3 medical complications was associated with increased one-year mortality OR, 2.42 [95% CI 1.25-4.69] and OR, 2.69 [95% CI 1.43-5.07], respectively. Sepsis, respiratory failure, and cardiac arrhythmias were associated with increased one-year mortality. Having 1, 2, or ≥3 pre-existing conditions was associated with increased odds of having medical complications in hospital. CONCLUSIONS Pre-existing conditions and in-hospital non-neurological medical complications are associated with increased one-year mortality in SAH. Pre-existing conditions are associated with increased medical complications.
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Bae IS, Chun HJ, Choi KS, Yi HJ. Modified Glasgow coma scale for predicting outcome after subarachnoid hemorrhage surgery. Medicine (Baltimore) 2021; 100:e25815. [PMID: 34106620 PMCID: PMC8133269 DOI: 10.1097/md.0000000000025815] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/13/2021] [Indexed: 11/26/2022] Open
Abstract
There are many grading scales that attempt to predict outcome following aneurysmal subarachnoid hemorrhage (aSAH). Most scales used to assess outcome are based on the neurological status of the patient. Here, we propose a new scale for aSAH patients that combines the Glasgow Coma Scale (GCS) and the modified Fisher scale (mFS).Five hundred ninety-seven patients with aSAH who were treated at our institution between January 2008 and December 2017 were retrospectively analyzed. Initial GCS score, Hunt and Hess scale, World Federation of Neurosurgical Societies scale, mFS, and modified Rankin Scale were obtained by reviewing data. Incidence of vasospasm was investigated. Factors found to be significant on a multivariable regression analysis were used to develop a scale that was compared with other grading systems using the area under the curve (AUC) calculated from receiver operating characteristic curve.The GCS score and mFS were related to outcomes in patients with aSAH. A simple score, which we call the GCS-F score, was calculated using these initial data. The GCS-F score had an AUC of 90.5% for unfavorable outcome prediction, and 88.4% for in-hospital mortality prediction. On the receiver operating characteristic curve analysis for vasospasm, the AUC for World Federation of Neurosurgical Societies, mFS and GCS-F scores were 0.912, 0.704, and 0.936, respectively.A simple arithmetic combination of the GCS score and mFS, the GCS-F score, includes the radiographic status as well as the clinical status of the patient, so that the state of the patient can be known in more detail than other single scales. The GCS-F score may be a useful scale for predicting outcome and the occurrence of vasospasm in patients with aSAH.
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Affiliation(s)
- In-Suk Bae
- Department of Neurosurgery, Nowon Eulji Medical Center, Eulji University, Nowon-gu
| | - Hyoung-Joon Chun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
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30
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Maldaner N, Zeitlberger AM, Sosnova M, Goldberg J, Fung C, Bervini D, May A, Bijlenga P, Schaller K, Roethlisberger M, Rychen J, Zumofen DW, D'Alonzo D, Marbacher S, Fandino J, Daniel RT, Burkhardt JK, Chiappini A, Robert T, Schatlo B, Schmid J, Maduri R, Staartjes VE, Seule MA, Weyerbrock A, Serra C, Stienen MN, Bozinov O, Regli L. Development of a Complication- and Treatment-Aware Prediction Model for Favorable Functional Outcome in Aneurysmal Subarachnoid Hemorrhage Based on Machine Learning. Neurosurgery 2021; 88:E150-E157. [PMID: 33017031 DOI: 10.1093/neuros/nyaa401] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/12/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Current prognostic tools in aneurysmal subarachnoid hemorrhage (aSAH) are constrained by being primarily based on patient and disease characteristics on admission. OBJECTIVE To develop and validate a complication- and treatment-aware outcome prediction tool in aSAH. METHODS This cohort study included data from an ongoing prospective nationwide multicenter registry on all aSAH patients in Switzerland (Swiss SOS [Swiss Study on aSAH]; 2009-2015). We trained supervised machine learning algorithms to predict a binary outcome at discharge (modified Rankin scale [mRS] ≤ 3: favorable; mRS 4-6: unfavorable). Clinical and radiological variables on admission ("Early" Model) as well as additional variables regarding secondary complications and disease management ("Late" Model) were used. Performance of both models was assessed by classification performance metrics on an out-of-sample test dataset. RESULTS Favorable functional outcome at discharge was observed in 1156 (62.0%) of 1866 patients. Both models scored a high accuracy of 75% to 76% on the test set. The "Late" outcome model outperformed the "Early" model with an area under the receiver operator characteristics curve (AUC) of 0.85 vs 0.79, corresponding to a specificity of 0.81 vs 0.70 and a sensitivity of 0.71 vs 0.79, respectively. CONCLUSION Both machine learning models show good discrimination and calibration confirmed on application to an internal test dataset of patients with a wide range of disease severity treated in different institutions within a nationwide registry. Our study indicates that the inclusion of variables reflecting the clinical course of the patient may lead to outcome predictions with superior predictive power compared to a model based on admission data only.
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Affiliation(s)
- Nicolai Maldaner
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Anna M Zeitlberger
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marketa Sosnova
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Christian Fung
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland.,Department of Neurosurgery, Medical Center - University of Freiburg, Germany
| | - David Bervini
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Adrien May
- Department of Neurosurgery, University Clinic Geneva, Geneva, Switzerland
| | - Philippe Bijlenga
- Department of Neurosurgery, University Clinic Geneva, Geneva, Switzerland
| | - Karl Schaller
- Department of Neurosurgery, University Clinic Geneva, Geneva, Switzerland
| | | | - Jonathan Rychen
- Department of Neurosurgery, Basel University Hospital, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurosurgery, Neurology, and Radiology, Maimonides Medical Center, SUNY Downstate University, Brooklyn, NY, USA
| | - Donato D'Alonzo
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Alessio Chiappini
- Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland
| | - Bawarjan Schatlo
- Department of Neurosurgery, University Hospital Göttingen, Germany
| | | | - Rodolfo Maduri
- Neurosurgery, Clinique de Genolier, Swiss Medical Network, Genolier, Switzerland
| | - Victor E Staartjes
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Martin A Seule
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Astrid Weyerbrock
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Martin Nikolaus Stienen
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
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Hostettler IC, Sebök M, Ambler G, Muroi C, Prömmel P, Neidert MC, Richter JK, Pangalu A, Regli L, Germans MR. Validation and Optimization of Barrow Neurological Institute Score in Prediction of Adverse Events and Functional Outcome After Subarachnoid Hemorrhage-Creation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score. Neurosurgery 2021; 88:96-105. [PMID: 32779716 DOI: 10.1093/neuros/nyaa316] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/24/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Barrow Neurological Institute (BNI) score, measuring maximal thickness of aneurysmal subarachnoid hemorrhage (aSAH), has previously shown to predict symptomatic cerebral vasospasms (CVSs), delayed cerebral ischemia (DCI), and functional outcome. OBJECTIVE To validate the BNI score for prediction of above-mentioned variables and cerebral infarct and evaluate its improvement by integrating further variables which are available within the first 24 h after hemorrhage. METHODS We included patients from a single center. The BNI score for prediction of CVS, DCI, infarct, and functional outcome was validated in our cohort using measurements of calibration and discrimination (area under the curve [AUC]). We improved it by adding additional variables, creating a novel risk score (measure by the dichotomized Glasgow Outcome Scale) and validated it in a small independent cohort. RESULTS Of 646 patients, 41.5% developed symptomatic CVS, 22.9% DCI, 23.5% cerebral infarct, and 29% had an unfavorable outcome. The BNI score was associated with all outcome measurements. We improved functional outcome prediction accuracy by including age, BNI score, World Federation of Neurologic Surgeons, rebleeding, clipping, and hydrocephalus (AUC 0.84, 95% CI 0.8-0.87). Based on this model we created a risk score (HATCH-Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus), ranging 0 to 13 points. We validated it in a small independent cohort. The validated score demonstrated very good discriminative ability (AUC 0.84 [95% CI 0.72-0.96]). CONCLUSION We developed the HATCH score, which is a moderate predictor of DCI, but excellent predictor of functional outcome at 1 yr after aSAH.
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Affiliation(s)
- Isabel Charlotte Hostettler
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Stroke Research Centre, University College London, Institute of Neurology, London, United Kingdom.,Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Martina Sebök
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Clinical Neuroscience Center Zurich, Zurich, Switzerland
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - Carl Muroi
- Neurocritical Care Unit, Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Peter Prömmel
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Johannes Konstantin Richter
- Department of Neuroradiology, University Hospital, University of Zurich, Zurich, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology (DIPR), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Athina Pangalu
- Department of Neuroradiology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Clinical Neuroscience Center Zurich, Zurich, Switzerland
| | - Menno Robbert Germans
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Clinical Neuroscience Center Zurich, Zurich, Switzerland
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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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Outcome prediction in aneurysmal subarachnoid hemorrhage: a comparison of machine learning methods and established clinico-radiological scores. Neurosurg Rev 2021; 44:2837-2846. [PMID: 33474607 PMCID: PMC8490233 DOI: 10.1007/s10143-020-01453-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/11/2020] [Accepted: 12/01/2020] [Indexed: 01/16/2023]
Abstract
Reliable prediction of outcomes of aneurysmal subarachnoid hemorrhage (aSAH) based on factors available at patient admission may support responsible allocation of resources as well as treatment decisions. Radiographic and clinical scoring systems may help clinicians estimate disease severity, but their predictive value is limited, especially in devising treatment strategies. In this study, we aimed to examine whether a machine learning (ML) approach using variables available on admission may improve outcome prediction in aSAH compared to established scoring systems. Combined clinical and radiographic features as well as standard scores (Hunt & Hess, WFNS, BNI, Fisher, and VASOGRADE) available on patient admission were analyzed using a consecutive single-center database of patients that presented with aSAH (n = 388). Different ML models (seven algorithms including three types of traditional generalized linear models, as well as a tree bosting algorithm, a support vector machine classifier (SVMC), a Naive Bayes (NB) classifier, and a multilayer perceptron (MLP) artificial neural net) were trained for single features, scores, and combined features with a random split into training and test sets (4:1 ratio), ten-fold cross-validation, and 50 shuffles. For combined features, feature importance was calculated. There was no difference in performance between traditional and other ML applications using traditional clinico-radiographic features. Also, no relevant difference was identified between a combined set of clinico-radiological features available on admission (highest AUC 0.78, tree boosting) and the best performing clinical score GCS (highest AUC 0.76, tree boosting). GCS and age were the most important variables for the feature combination. In this cohort of patients with aSAH, the performance of functional outcome prediction by machine learning techniques was comparable to traditional methods and established clinical scores. Future work is necessary to examine input variables other than traditional clinico-radiographic features and to evaluate whether a higher performance for outcome prediction in aSAH can be achieved.
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Imaging Predictors of Vasospasm and Delayed Cerebral Ischaemia After Subarachnoid Haemorrhage. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00653-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gracia Arnillas MP, Alvarez-Lerma F, Masclans JR, Roquer J, Soriano C, Manzano D, Zapatero A, Diaz Y, Duran X, Castellví A, Cuadrado E, Ois A. Impact of adrenomedullin levels on clinical risk stratification and outcome in subarachnoid haemorrhage. Eur J Clin Invest 2020; 50:e13318. [PMID: 32535893 DOI: 10.1111/eci.13318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To use classification tree analysis to identify risk factors for nonsurvival in a neurological patients with subarachnoid haemorrhage (SAH) and to propose a clinical model for predicting of mortality. METHODS Prospective study of SAH admitted to a Critical Care Department and Stroke Unit over a 2-year period. Middle region of pro-ADM plasma levels (MR-proADM) was measured in EDTA plasma within the first 24 hours of hospital admission using the automatic immunofluorescence test. A regression tree was made to identify prognostic models for the development of mortality at 90 days. RESULTS Ninety patients were included. The mean MR-proADM plasma value in the samples analysed was 0.78 ± 0.41 nmol/L. MR-proADM plasma levels were significantly associated with mortality at 90 days (1.05 ± 0.51 nmol/L vs 0.64 ± 0.25 nmol/L; P < .001). Regression tree analysis provided an algorithm based on the combined use of clinical variables and one biomarker allowing accurate mortality discrimination of three distinct subgroups with high risk of 90-day mortality ranged from 75% to 100% (AUC 0.9; 95% CI 0.83-0.98). CONCLUSIONS The study established a model (APACHE II, MR-proADM and Hunt&Hess) to predict fatal outcomes in patients with SAH. The proposed decision-making algorithm may help identify patients with a high risk of mortality.
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Affiliation(s)
- Maria Pilar Gracia Arnillas
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Francisco Alvarez-Lerma
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Jose-Ramón Masclans
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Jaume Roquer
- Department of Neurology, Neurovascular Research Group, IMIM- Hospital del Mar, Barcelona, Spain
| | - Carolina Soriano
- IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Demian Manzano
- Neurosurgery Department, Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
| | - Ans Zapatero
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Yolanda Diaz
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Xavi Duran
- AMIB Methodological and Biostatistical Advice IMIM, IMIM- Hospital del Mar, Barcelona, Spain
| | - Andrea Castellví
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain
| | - Elisa Cuadrado
- Department of Neurology, Neurovascular Research Group, IMIM- Hospital del Mar, Barcelona, Spain
| | - Angel Ois
- Department of Neurology, Neurovascular Research Group, IMIM- Hospital del Mar, Barcelona, Spain
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Mourelo-Fariña M, Pértega S, Galeiras R. A Model for Prediction of In-Hospital Mortality in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2020; 34:508-518. [PMID: 32671649 DOI: 10.1007/s12028-020-01041-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite being a rare cause of stroke, spontaneous subarachnoid hemorrhage (SAH) is associated with high mortality rates. The prediction models that are currently being used on SAH patients are heterogeneous, and few address premature mortality. The aim of this study was to develop a mortality risk stratification score for SAH. METHODS A retrospective study was carried out with 536 patients diagnosed with SAH who had been admitted to the intensive care unit (ICU) at the University Hospital Complex of A Coruña (Spain) between 2003 and 2013. A multivariate logistic regression model was developed to predict the likelihood of in-hospital mortality, adjusting it exclusively for variables present on admission. A predictive equation of in-hospital mortality was then computed based on the model's coefficients, along with a points-based risk-scoring system. Its discrimination ability was also tested based on the area under the receiver operating characteristics curve and compared with previously developed scores. RESULTS The mean age of the patients included in this study was 56.9 ± 14.1 years. Most of these patients (73.9%) had been diagnosed with aneurysmal SAH. Their median length of stay was 7 days in the ICU and 20 days in the general hospital ward, with an overall in-hospital mortality rate of 28.5%. The developed scales included the following admission variables independently associated with in-hospital mortality: coma at onset [odds ratio (OR) = 1.87; p = 0.028], Fisher scale score of 3-4 (OR = 2.27; p = 0.032), Acute Physiology and Chronic Health Evaluation II (APACHE II) score within the first 24 h (OR = 1.10; p < 0.001), and total Sequential Organ Failure Assessment (SOFA) score on day 0 (OR = 1.19; p = 0.004). Our predictive equation demonstrated better discrimination [area under the curve (AUC) = 0.835] (bootstrap-corrected AUC = 0.831) and calibration properties than those of the HAIR scale (AUC = 0.771; p ≤ 0.001) and the Functional Recovery Expected after Subarachnoid Hemorrhage scale (AUC = 0.814; p = 0.154). CONCLUSIONS In addition to the conventional risk factors for in-hospital mortality, in our study, mortality was associated with the presence of coma at onset of the condition, the physiological variables assessed by means of the APACHE II scale within the first 24 h, and the total SOFA score on day 0. A simple prediction model of mortality was developed with novel parameters assessed on admission, which also assessed organ failure and did not require a previous etiological diagnosis.
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Affiliation(s)
- Mónica Mourelo-Fariña
- Critical Care Unit, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), SERGAS, Universidade de A Coruña (UDC), As Xubias, 15006, A Coruña, Spain.
| | - Sonia Pértega
- Clinical Epidemiology and Biostatistics Unit, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), SERGAS, Universidade de A Coruña (UDC), As Xubias, 15006, A Coruña, Spain
| | - Rita Galeiras
- Critical Care Unit, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), SERGAS, Universidade de A Coruña (UDC), As Xubias, 15006, A Coruña, Spain
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Wartenberg KE, Hwang DY, Haeusler KG, Muehlschlegel S, Sakowitz OW, Madžar D, Hamer HM, Rabinstein AA, Greer DM, Hemphill JC, Meixensberger J, Varelas PN. Gap Analysis Regarding Prognostication in Neurocritical Care: A Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society. Neurocrit Care 2020; 31:231-244. [PMID: 31368059 PMCID: PMC6757096 DOI: 10.1007/s12028-019-00769-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background/Objective Prognostication is a routine part of the delivery of neurocritical care for most patients with acute neurocritical illnesses. Numerous prognostic models exist for many different conditions. However, there are concerns about significant gaps in knowledge regarding optimal methods of prognostication. Methods As part of the Arbeitstagung NeuroIntensivMedizin meeting in February 2018 in Würzburg, Germany, a joint session on prognostication was held between the German NeuroIntensive Care Society and the Neurocritical Care Society. The purpose of this session was to provide presentations and open discussion regarding existing prognostic models for eight common neurocritical care conditions (aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, traumatic spinal cord injury, status epilepticus, Guillain–Barré Syndrome, and global cerebral ischemia from cardiac arrest). The goal was to develop a qualitative gap analysis regarding prognostication that could help inform a future framework for clinical studies and guidelines. Results Prognostic models exist for all of the conditions presented. However, there are significant gaps in prognostication in each condition. Furthermore, several themes emerged that crossed across several or all diseases presented. Specifically, the self-fulfilling prophecy, lack of accounting for medical comorbidities, and absence of integration of in-hospital care parameters were identified as major gaps in most prognostic models. Conclusions Prognostication in neurocritical care is important, and current prognostic models are limited. This gap analysis provides a summary assessment of issues that could be addressed in future studies and evidence-based guidelines in order to improve the process of prognostication.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care and Stroke Unit, Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520-8018, USA
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Strasse 11, 97080, Würzburg, Germany
| | - Susanne Muehlschlegel
- Department of Neurology, Anesthesiology and Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Oliver W Sakowitz
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Dominik Madžar
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hajo M Hamer
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | | | - David M Greer
- Department of Neurology, Boston University Medical Center, 72 East Concord St, Boston, MA, 02118, USA
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Juergen Meixensberger
- Department of Neurosurgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Panayiotis N Varelas
- Department of Neurology and Neurosurgery, Henry Ford Hospital, 2799 W. Grand Blvd Neurosurgery - K-11, Detroit, MI, 48202, USA
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Comparison of aneurysmal subarachnoid hemorrhage grading scores in patients with aneurysm clipping and coiling. Sci Rep 2020; 10:9199. [PMID: 32513925 PMCID: PMC7280262 DOI: 10.1038/s41598-020-66160-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/13/2020] [Indexed: 11/28/2022] Open
Abstract
Past studies revealed the prognosis differed between aneurysmal subarachnoid hemorrhage (aSAH) patients with surgical clipping and endovascular coiling. We retrospectively reviewed aSAH patients in our institution to investigate the effectiveness of grading scores between two groups. In the surgical clipping group (n = 349), VASOGRADE had a favorable performance for predicting delayed cerebral ischemia (DCI) (area under curve (AUC) > 0.750), and had better results than clinical (World Federation of Neurosurgical Societies (WFNS), Hunt & Hess (HH) and radiological scores (modified Fisher Scale (mFS), Subarachnoid Hemorrhage Early Brain Edema Score) (P < 0.05). Clinical and combined scores (VASOGRADE, HAIR) had favorable performance for predicting poor outcome (AUC > 0.750), and had better results than radiological scores (P < 0.05). In the coiling group (n = 320), none of the grading scores demonstrated favorable predictive accuracy for DCI (AUC < 0.750). Only WFNS and VASOGRADE had AUC > 0.700, with better performance than mFS (P < 0.05). The clinical and combined scores showed favorable performance for predicting a poor outcome (AUC > 0.750), and were better than the radiological scores (P < 0.05). Radiological scores appeared inferior to the clinical and combined scores in clipping and coiling groups. VASOGRADE can be an effective grading score in patients with clipping or coiling for predicting DCI and poor outcome.
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Mader MM, Piffko A, Dengler NF, Ricklefs FL, Dührsen L, Schmidt NO, Regelsberger J, Westphal M, Wolf S, Czorlich P. Initial pupil status is a strong predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage. Sci Rep 2020; 10:4764. [PMID: 32179801 PMCID: PMC7076009 DOI: 10.1038/s41598-020-61513-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/27/2020] [Indexed: 11/30/2022] Open
Abstract
Prognosis of patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) is only insufficiently displayed by current standard prognostic scores. This study aims to evaluate the role of pupil status for mortality prediction and provide improved prognostic models. Anonymized data of 477 aSAH patients admitted to our medical center from November 2010 to August 2018 were retrospectively analyzed. Identification of variables independently predicting in-hospital mortality was performed by multivariable logistic regression analysis. Final regression models included Hunt & Hess scale (H&H), pupil status and age or in a simplified variation only H&H and pupil status, leading to the design of novel H&H-Pupil-Age score (HHPA) and simplified H&H-Pupil score (sHHP), respectively. In an external validation cohort of 402 patients, areas under the receiver operating characteristic curves (AUROC) of HHPA (0.841) and sHHP (0.821) were significantly higher than areas of H&H (0.794; p < 0.001) or World Federation of Neurosurgical Societies (WFNS) scale (0.775; p < 0.01). Accordingly, including information about pupil status improves the predictive performance of prognostic scores for in-hospital mortality in patients with aSAH. HHPA and sHHP allow simple, early and detailed prognosis assessment while predictive performance remained strong in an external validation cohort suggesting adequate generalizability and low interrater variability.
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Affiliation(s)
- Marius M Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany. .,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, 265 Campus Drive, Stanford, CA, 94305, USA.
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nora F Dengler
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nils O Schmidt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Validation and Comparison of Aneurysmal Subarachnoid Hemorrhage Grading Scales in Angiogram-Negative Subarachnoid Hemorrhage Patients. BIOMED RESEARCH INTERNATIONAL 2020; 2020:9707238. [PMID: 32190693 PMCID: PMC7071792 DOI: 10.1155/2020/9707238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 02/13/2020] [Indexed: 12/15/2022]
Abstract
Numerous grading scales have been proposed to predict the outcome of aneurysmal subarachnoid hemorrhage (SAH); however, these have not been validated in angiogram-negative SAH patients. In this study, we aim to validate and compare the aneurysmal SAH grading scales in angiogram-negative SAH patients. There were 190 angiogram-negative SAH patients analyzed from January 2014 to December 2015. The outcomes were measured by delayed cerebral ischemia (DCI) and poor outcome (defined as modified Rankin Scale (mRS) 3-6 or 4-6). The predictive performance of the grading scales was assessed via evaluation of distribution, trend, association, and discrimination. In regard to the distribution, none of the patients were categorized as HAIR 8 and SAH score 8. Both grading scales indicated a significant trend between scores and outcome (P < 0.05), and association with the outcome (OR > 1). The modified Fisher Scale (mFS), World Federation of Neurosurgical Societies scale (WFNS), and combined scores VASOGRADE and HAIR showed good predictive accuracy (area under the curve (AUC) > 0.750) for DCI. The predictive accuracy in each scale performed well in predicting poor outcome, with the exception of mFS and the Subarachnoid hemorrhage Early Brain Edema Score (SEBES). However, the mFS performed with increased accuracy when predicting mRS 4-6. The VASOGRADE, HAIR, and WFNS may be valuable prognostic tools for predicting both DCI and poor outcome. The mFS can be applicable for predicting DCI and mRS 4-6. The SAH score and the Hunt-Hess were also optimal for predicting poor outcome. The predictive performance of SEBES was relatively poor compared to the other scales.
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Rau CS, Wu SC, Hsu SY, Liu HT, Huang CY, Hsieh TM, Chou SE, Su WT, Liu YW, Hsieh CH. Concurrent Types of Intracranial Hemorrhage are Associated with a Higher Mortality Rate in Adult Patients with Traumatic Subarachnoid Hemorrhage: A Cross-Sectional Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16234787. [PMID: 31795322 PMCID: PMC6926691 DOI: 10.3390/ijerph16234787] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 11/30/2022]
Abstract
Traumatic subarachnoid hemorrhage (SAH) is the second most frequent intracranial hemorrhage and a common radiologic finding in computed tomography. This study aimed to estimate the risk of mortality in adult trauma patients with traumatic SAH concurrent with other types of intracranial hemorrhage, such as subdural hematoma (SDH), epidural hematoma (EDH), and intracerebral hemorrhage (ICH), compared to the risk in patients with isolated traumatic SAH. We searched our hospital’s trauma database from 1 January, 2009 to 31 December, 2018 to identify hospitalized adult patients ≥20 years old who presented with a trauma abbreviated injury scale (AIS) of ≥3 in the head region. Polytrauma patients with an AIS of ≥3 in any other region of the body were excluded. A total of 1856 patients who had SAH were allocated into four exclusive groups: (Group I) isolated traumatic SAH, n = 788; (Group II) SAH and one diagnosis, n = 509; (Group III) SAH and two diagnoses, n = 493; and (Group IV) SAH and three diagnoses, n = 66. One, two, and three diagnoses indicated occurrences of one, two, or three other types of intracranial hemorrhage (SDH, EDH, or ICH). The adjusted odds ratio with a 95% confidence interval (CI) of the level of mortality was calculated with logistic regression, controlling for sex, age, and pre-existing comorbidities. Patients with isolated traumatic SAH had a lower rate of mortality (1.8%) compared to the other three groups (Group II: 7.9%, Group III: 12.4%, and Group IV: 27.3%, all p < 0.001). When controlling for sex, age, and pre-existing comorbidities, we found that Group II, Group III, and Group IV patients had a 4.0 (95% CI 2.4–6.5), 8.9 (95% CI 4.8–16.5), and 21.1 (95% CI 9.4–47.7) times higher adjusted odds ratio for mortality, respectively, than the patients with isolated traumatic SAH. In this study, we demonstrated that compared to patients with isolated traumatic SAH, traumatic SAH patients with concurrent types of intracranial hemorrhage have a higher adjusted odds ratio for mortality.
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Affiliation(s)
- Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan;
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan;
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Hang-Tsung Liu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Chun-Ying Huang
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Ting-Min Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Sheng-En Chou
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Wei-Ti Su
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan; (S.-Y.H.); (H.-T.L.); (C.-Y.H.); (T.-M.H.); (S.-E.C.); (W.-T.S.)
| | - Yueh-Wei Liu
- Department of General Gurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan
- Correspondence: (Y.-W.L.); (C.-H.H.); Tel.: +886-7-345-4746 (C.-H.H.)
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan
- Correspondence: (Y.-W.L.); (C.-H.H.); Tel.: +886-7-345-4746 (C.-H.H.)
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Roelz R, Scheiwe C, Urbach H, Coenen VA, Reinacher P. Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage in Patients with Coiled Aneurysms. Oper Neurosurg (Hagerstown) 2019; 14:231-235. [PMID: 28582545 DOI: 10.1093/ons/opx129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 05/01/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Current treatments of cerebral vasospasm are insufficient. Cisternal blood clearance is a promising treatment option. However, a generally applicable, safe, and effective method to access the cisterns of the brain is lacking. OBJECTIVE To report on stereotactic catheter ventriculocisternostomy (STX-VCS) as a method to access the cisterns of the brain for clearance of subarachnoid hemorrhage in patients with aSAH and coiled aneurysms. METHODS In 9 aSAH patients at high risk for DCI (Hunt and Hess grade ≥3, modified Fisher grade ≥3), access to the basal cisterns of the brain was created by STX-VCS. Fibrinolytic and/or spasmolytic lavage therapy was administered. RESULTS STX-VCS was feasible and safe in all patients. Subarachnoid blood was rapidly cleared by irrigation with urokinase. Vasospasm occurred in 2 patients and was interrupted by irrigation with nimodipine. There was 1 fatality due to pneumogenic sepsis. Minor DCI occurred in 1 patient. Eight survived without DCI and are independent (modified Rankin score [mRS] ≤ 3) at 6 mo after aSAH. CONCLUSION STX-VCS allows for rapid clearance of subarachnoid hemorrhage in patients with coiled aneurysms.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradio-logy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurg-ery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Peter Reinacher
- Department of Stereotactic and Functional Neurosurg-ery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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Hostettler IC, Muroi C, Richter JK, Schmid J, Neidert MC, Seule M, Boss O, Pangalu A, Germans MR, Keller E. Decision tree analysis in subarachnoid hemorrhage: prediction of outcome parameters during the course of aneurysmal subarachnoid hemorrhage using decision tree analysis. J Neurosurg 2019; 129:1499-1510. [PMID: 29350603 DOI: 10.3171/2017.7.jns17677] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/06/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe aim of this study was to create prediction models for outcome parameters by decision tree analysis based on clinical and laboratory data in patients with aneurysmal subarachnoid hemorrhage (aSAH).METHODSThe database consisted of clinical and laboratory parameters of 548 patients with aSAH who were admitted to the Neurocritical Care Unit, University Hospital Zurich. To examine the model performance, the cohort was randomly divided into a derivation cohort (60% [n = 329]; training data set) and a validation cohort (40% [n = 219]; test data set). The classification and regression tree prediction algorithm was applied to predict death, functional outcome, and ventriculoperitoneal (VP) shunt dependency. Chi-square automatic interaction detection was applied to predict delayed cerebral infarction on days 1, 3, and 7.RESULTSThe overall mortality was 18.4%. The accuracy of the decision tree models was good for survival on day 1 and favorable functional outcome at all time points, with a difference between the training and test data sets of < 5%. Prediction accuracy for survival on day 1 was 75.2%. The most important differentiating factor was the interleukin-6 (IL-6) level on day 1. Favorable functional outcome, defined as Glasgow Outcome Scale scores of 4 and 5, was observed in 68.6% of patients. Favorable functional outcome at all time points had a prediction accuracy of 71.1% in the training data set, with procalcitonin on day 1 being the most important differentiating factor at all time points. A total of 148 patients (27%) developed VP shunt dependency. The most important differentiating factor was hyperglycemia on admission.CONCLUSIONSThe multiple variable analysis capability of decision trees enables exploration of dependent variables in the context of multiple changing influences over the course of an illness. The decision tree currently generated increases awareness of the early systemic stress response, which is seemingly pertinent for prognostication.
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Affiliation(s)
- Isabel Charlotte Hostettler
- Departments of1Neurosurgery and.,2Stroke Research Centre, University College London, Institute of Neurology, London, United Kingdom
| | - Carl Muroi
- 3Neurocritical Care Unit, Department of Neurosurgery, University Hospital Zurich
| | - Johannes Konstantin Richter
- 4Neuroradiology and.,5Department of Diagnostic, Interventional and Pediatric Radiology, University Hospital of Bern
| | | | | | - Martin Seule
- 3Neurocritical Care Unit, Department of Neurosurgery, University Hospital Zurich.,7Department of Neurosurgery, Kantonsspital St. Gallen, Switzerland; and
| | - Oliver Boss
- 3Neurocritical Care Unit, Department of Neurosurgery, University Hospital Zurich
| | | | | | - Emanuela Keller
- Departments of1Neurosurgery and.,3Neurocritical Care Unit, Department of Neurosurgery, University Hospital Zurich
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Fang YJ, Mei SH, Lu JN, Chen YK, Chai ZH, Dong X, Araujo C, Reis C, Zhang JM, Chen S. New risk score of the early period after spontaneous subarachnoid hemorrhage: For the prediction of delayed cerebral ischemia. CNS Neurosci Ther 2019; 25:1173-1181. [PMID: 31407513 PMCID: PMC6776741 DOI: 10.1111/cns.13202] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 01/09/2023] Open
Abstract
Background and Purpose The aim of this study is to identify the early predictors for delayed cerebral ischemia (DCI) and develop a risk stratification score by focusing on the early change after aneurysmal subarachnoid hemorrhage (aSAH). Methods The study retrospectively reviewed aSAH patients between 2014 and 2015. Risk factors within 72 hours after aSAH were included into univariable and multivariable logistic regression analysis to screen the independent predictors for DCI and to design a risk stratification score. Results We analyzed 702 aSAH patients; four predictors were retained from the final multivariable analysis: World Federation of Neurosurgical Societies scale (WFNS; OR = 4.057, P < .001), modified Fisher Scale (mFS; OR = 2.623, P < .001), Subarachnoid Hemorrhage Early Brain Edema Score (SEBES; OR = 1.539, P = .036), and intraventricular hemorrhage (IVH; OR = 1.932, P = .002). According to the regression coefficient, we created a risk stratification score ranging from 0 to 7 (WFNS = 3, mFS = 2, SEBES = 1, and IVH = 1). The new score showed a significantly higher area under curve (0.785) compared with other scores (P < .001). Conclusion The early DCI score provides a practical method at the early 72 hours after aSAH to predict DCI.
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Affiliation(s)
- Yuan-Jian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shu-Hao Mei
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jia-Nan Lu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi-Ke Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhao-Hui Chai
- Department of Neurosurgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao Dong
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Camila Araujo
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jian-Min Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Brain Research Institute, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, China
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Witsch J, Kuohn L, Hebert R, Cord B, Sansing L, Gilmore EJ, Hwang DY, Petersen N, Falcone GJ, Matouk C, Sheth KN. Early Prognostication of 1-Year Outcome After Subarachnoid Hemorrhage: The FRESH Score Validation. J Stroke Cerebrovasc Dis 2019; 28:104280. [PMID: 31326270 DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIM The FRESH score is a tool to prognosticate long-term outcomes after spontaneous subarachnoid hemorrhage (SAH). Here, for the first time, we aimed to externally validate the disability part of FRESH using its original four score variables. METHODS A total of 107 patients with SAH were prospectively enrolled in the Yale Acute Brain Injury Biorepository between September 2014 and January 2018. 12-month functional outcome was recorded prospectively by trained study investigators using the modified Rankin Scale (mRS). FRESH-scores were calculated retrospectively using the original score variables. We used R2 statistics to assess goodness of fit, and the area under the receiver operating characteristic curve (AUC) to assess ability of the score to discriminate between favorable and unfavorable (defined as mRS 4-6) outcome. RESULTS We identified 86 patients with SAH with complete 1-year follow-up data. Mean age was 60 years, 60% were women. An aneurysmal bleeding source was found in 71% of patients. 80% underwent aneurysm coiling, and 5% clipping. Sixteen percent of patients were considered high grade on admission (Hunt&Hess score 4 or 5). Discrimination of the FRESH score between favorable and unfavorable outcome was high (AUC 90.8%, confidence interval 81.9%-96.5%). Nagelkerke's (.54) and Cox&Snell's R2 (.35) indicated satisfactory fit. Exclusion of patients without aneurysmal etiology of SAH did not significantly alter model performance. CONCLUSIONS FRESH, a prognostication score of long-term outcomes in patients with SAH showed excellent score performance in this external validation. FRESH may guide the efficient use of hospital resources, family discussions, and stratification of patients in future randomized controlled trials.
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Affiliation(s)
- Jens Witsch
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut.
| | - Lindsey Kuohn
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Ryan Hebert
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Branden Cord
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Lauren Sansing
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Nils Petersen
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Anqi X, Ruiqi C, Yanming R, Chao Y. Elevated hemoglobin is associated with poor prognosis in Tibetans with poor-grade aneurysmal subarachnoid hemorrhage after clipping: A Retrospective Case-Control Study. Neurochirurgie 2019; 65:365-369. [PMID: 31301387 DOI: 10.1016/j.neuchi.2019.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/19/2019] [Accepted: 06/10/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES High hemoglobin (HGB) concentration is frequently seen in Tibetans in clinical practice; however, the impact on postsurgical prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is not precisely known. Thus, we sought to understand the association between high HGB level and postoperative outcome in Tibetans with poor-grade aSAH. PATIENTS AND METHODS Results of clipping in consecutive Tibetan patients with poor-grade aSAH were analyzed retrospectively for the period January 2012 to January 2017. Based on the upper limit (160g/L) of normal hemoglobin levels, patients were divided to a high (HHC) and a normal (NHC) HGB-level cohort according to the first routine blood result on admission. Propensity score matching was used for baseline matching in the 2 cohorts. Postoperative complications in the 2 groups were compared. Prognosis after ictus, including 6-month neurological functional status and mortality at 30 days and 6 months were also assessed. RESULTS Risk of ischemia, pulmonary embolism and lower-limb deep venous thrombosis (DVT) was higher in HHC than NHC (62.88% vs. 21.64%; P<0.001; 10.30% vs. 1.31%, P<0.005; 24.74% vs. 7.21%, P<0.001, respectively). Hospital stay also differed significantly (15.82±3.86 vs. 10.37±4.80 days; P<0.001). Out of the 194 patients, 150 survived at 6 months. At 6-month neurological functional follow-up, 8 NHC patients had favorable modified Rankin scale (mRS) scores ≤2 at discharge, versus only 1 HHC patient, showing better outcome in NHC than HHC (8.25% vs. 1.03%; P=0.035). In-hospital mortality was significantly greater in HHC than NHC (17.52% vs. 7.22%; P=0.029). 30-day post-ictus mortality was 30.93% in HHC versus 14.43% in NHC (P<0.006). There was also a significant difference in mortality at 6 months post-ictus (47.42% vs. 18.56%; P<0.001). CONCLUSION High HGB level was associated with increased risk of postsurgical cerebral ischemia, pulmonary embolism and lower-limb DVT and poor prognosis in poor-grade aSAH patients. Preoperative hemodilution therapy might be beneficial in reducing operative complications, reducing hospital stay and improving short-term prognosis for neurological functional recovery in aSAH patients with high HGB concentration, but further detailed research is needed.
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Affiliation(s)
- X Anqi
- Department of Neurosurgery, West China Hospital, Sichuan, University, Chengdu 610041, P.R. China.
| | - C Ruiqi
- Department of Neurosurgery, West China Hospital, Sichuan, University, Chengdu 610041, P.R. China.
| | - R Yanming
- Department of Neurosurgery, West China Hospital, Sichuan, University, Chengdu 610041, P.R. China.
| | - Y Chao
- Department of Neurosurgery, West China Hospital, Sichuan, University, Chengdu 610041, P.R. China.
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Jabbarli R, Pierscianek D, Rölz R, Darkwah Oppong M, Kaier K, Shah M, Taschner C, Mönninghoff C, Urbach H, Beck J, Sure U, Forsting M. Endovascular treatment of cerebral vasospasm after subarachnoid hemorrhage. Neurology 2019; 93:e458-e466. [DOI: 10.1212/wnl.0000000000007862] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/21/2019] [Indexed: 12/20/2022] Open
Abstract
ObjectiveDelayed cerebral ischemia (DCI) is strongly associated with poor outcome after subarachnoid hemorrhage (SAH). Cerebral vasospasm is a major contributor to DCI and requires special attention. To evaluate the effect of vasospasm management on SAH outcome, we performed a pooled analysis of 2 observational SAH cohorts.MaterialsData from 2 institutional databases with consecutive patients with SAH treated between 2005 and 2012 were pooled. The effect of 2 institutional standards of conservative and endovascular vasospasm treatment (EVT) on the rates of DCI (new cerebral infarcts not visible on the post-treatment imaging) and unfavorable outcome (modified Rankin Scale score >2) at 6 months follow-up was analyzed.ResultsThe final analysis included 1,057 patients with SAH. There was no difference regarding demographic (age and sex), clinical (Hunt & Hess grades, acute hydrocephalus, treatment modality, and infections), and radiographic (Fisher grades and aneurysm location) characteristics of the populations. However, there was a significant difference in the rate (24.4% [121/495] vs 14.4% [81/562], p < 0.0001) and timing (first treatment on day 6 vs 8.9 after SAH, p < 0.0001) of EVT. The rates of DCI (20.8% vs 29%, p = 0.0001) and unfavorable outcome (44% vs 50.6%, p = 0.04) were lower in the cohort with more frequent and early EVT. Multivariate analysis confirmed independent effect of EVT standard on DCI risk and outcome.ConclusionsA preventive strategy utilizing frequent and early EVT seems to reduce the risk of DCI in patients with SAH and improve their functional outcome. We recommend prospective evaluation of the value of preventive EVT strategy on SAH.Classification of evidenceThis study provides Class III evidence that for patients with SAH, a frequent and early EVT to treat vasospasm reduces the risk of DCI and improves functional outcome.
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48
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The effectiveness of lumbar cerebrospinal fluid drainage in aneurysmal subarachnoid hemorrhage with different bleeding amounts. Neurosurg Rev 2019; 43:739-747. [DOI: 10.1007/s10143-019-01116-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/07/2019] [Accepted: 05/17/2019] [Indexed: 11/27/2022]
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Taran S, Trivedi V, Singh JM, English SW, McCredie VA. The use of standardized management protocols for critically ill patients with non-traumatic subarachnoid hemorrhage: a protocol of a systematic review and meta-analysis. Syst Rev 2018; 7:53. [PMID: 29609651 PMCID: PMC5880023 DOI: 10.1186/s13643-018-0716-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 03/20/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Caring for patients with subarachnoid hemorrhage (SAH) presents unique challenges, due in part to the severity of the underlying insult, competing systemic injuries, and unpredictable clinical course. Even when management occurs in dedicated critical care settings, treatment uncertainty often persists, and morbidity and mortality from the condition remain high. Complex decisions in SAH care may be simplified with the use of standardized management protocols (SMPs). SMPs incorporate evidence-based guidelines into a practical framework for decision-making, thereby providing clinicians with an algorithm for organizing treatments. But despite these potential advantages, it is currently unknown whether SMPs may improve outcomes in the critical care of patients with SAH. METHODS We will conduct a systematic review of cohort studies and randomized control trials of adult patients with non-traumatic SAH who received care according to a standardized management protocol. Comprehensive search strategies will be developed for MEDLINE, EMBASE, WoS, CINAHL, and CENTRAL, to identify studies for review. The gray literature will be scanned for further eligible studies. Two reviewers will independently screen the material generated by the search to identify studies for inclusion. A standardized data extraction form will be used to collect information on study design, baseline characteristics, details of the management protocol employed, and primary and secondary outcomes. Where possible, meta-analyses with random-effects models will be used to calculate pooled estimates of effect sizes. Statistical heterogeneity will be evaluated with the I2 statistics, and risk of bias and reporting quality will be assessed independently and in duplicate with standardized scales. DISCUSSION We anticipate a significant degree of clinical heterogeneity in our review, as protocols will likely vary in their content, implementation, and ICU setting. We will aim to summarize the current literature in this domain to understand if SMPs, as a low-cost process-targeted intervention, improve outcomes for critically ill patients with SAH. Our review will additionally inform future research endeavors to improve the processes of care for this patient population. SYSTEMATIC REVIEW REGISTRATION CRD42017069173.
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Affiliation(s)
- Shaurya Taran
- Division of Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
- Department of Medicine, University Health Network, 200 Elizabeth Street, Eaton Building 14-217, Toronto, ON M5G 2C4 Canada
| | - Vatsal Trivedi
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON Canada
| | - Jeffrey M. Singh
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
- Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON Canada
| | - Shane W. English
- Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, ON Canada
| | - Victoria A. McCredie
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
- Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON Canada
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50
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Zafar SF, Postma EN, Biswal S, Fleuren L, Boyle EJ, Bechek S, O'Connor K, Shenoy A, Jonnalagadda D, Kim J, Shafi MS, Patel AB, Rosenthal ES, Westover MB. Electronic Health Data Predict Outcomes After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2018; 28:184-193. [PMID: 28983801 PMCID: PMC5886829 DOI: 10.1007/s12028-017-0466-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUD Using electronic health data, we sought to identify clinical and physiological parameters that in combination predict neurologic outcomes after aneurysmal subarachnoid hemorrhage (aSAH). METHODS We conducted a single-center retrospective cohort study of patients admitted with aSAH between 2011 and 2016. A set of 473 predictor variables was evaluated. Our outcome measure was discharge Glasgow Outcome Scale (GOS). For laboratory and physiological data, we computed the minimum, maximum, median, and variance for the first three admission days. We created a penalized logistic regression model to determine predictors of outcome and a multivariate multilevel prediction model to predict poor (GOS 1-2), intermediate (GOS 3), or good (GOS 4-5) outcomes. RESULTS One hundred and fifty-three patients met inclusion criteria; most were discharged with a GOS of 3. Multivariate analysis predictors of mortality (AUC 0.9198) included APACHE II score, Glasgow Come Scale (GCS), white blood cell (WBC) count, mean arterial pressure, variance of serum glucose, intracranial pressure (ICP), and serum sodium. Predictors of death/dependence versus independence (GOS 4-5)(AUC 0.9456) were levetiracetam, mechanical ventilation, WBC count, heart rate, ICP variance, GCS, APACHE II, and epileptiform discharges. The multiclass prediction model selected GCS, admission APACHE II, periodic discharges, lacosamide, and rebleeding as significant predictors; model performance exceeded 80% accuracy in predicting poor or good outcome and exceeded 70% accuracy for predicting intermediate outcome. CONCLUSIONS Variance in early physiologic data can impact patient outcomes and may serve as targets for early goal-directed therapy. Electronically retrievable features such as ICP, glucose levels, and electroencephalography patterns should be considered in disease severity and risk stratification scores.
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Affiliation(s)
- Sahar F Zafar
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Eva N Postma
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Siddharth Biswal
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Lucas Fleuren
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Emily J Boyle
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sophia Bechek
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Kathryn O'Connor
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Apeksha Shenoy
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Durga Jonnalagadda
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Jennifer Kim
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Mouhsin S Shafi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Eric S Rosenthal
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - M Brandon Westover
- Department of Neurology, Lunder 6 Neurosciences Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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