1
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Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [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: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
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Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
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2
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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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3
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Dodd WS, Laurent D, Dumont AS, Hasan DM, Jabbour PM, Starke RM, Hosaka K, Polifka AJ, Hoh BL, Chalouhi N. Pathophysiology of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: A Review. J Am Heart Assoc 2021; 10:e021845. [PMID: 34325514 PMCID: PMC8475656 DOI: 10.1161/jaha.121.021845] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/09/2021] [Indexed: 01/23/2023]
Abstract
Delayed cerebral ischemia is a major predictor of poor outcomes in patients who suffer subarachnoid hemorrhage. Treatment options are limited and often ineffective despite many years of investigation and clinical trials. Modern advances in basic science have produced a much more complex, multifactorial framework in which delayed cerebral ischemia is better understood and novel treatments can be developed. Leveraging this knowledge to improve outcomes, however, depends on a holistic understanding of the disease process. We conducted a review of the literature to analyze the current state of investigation into delayed cerebral ischemia with emphasis on the major themes that have emerged over the past decades. Specifically, we discuss microcirculatory dysfunction, glymphatic impairment, inflammation, and neuroelectric disruption as pathological factors in addition to the canonical focus on cerebral vasospasm. This review intends to give clinicians and researchers a summary of the foundations of delayed cerebral ischemia pathophysiology while also underscoring the interactions and interdependencies between pathological factors. Through this overview, we also highlight the advances in translational studies and potential future therapeutic opportunities.
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Affiliation(s)
- William S. Dodd
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Dimitri Laurent
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Aaron S. Dumont
- Department of Neurological SurgerySchool of MedicineTulane UniversityNew OrleansLA
| | - David M. Hasan
- Department of NeurosurgeryCarver College of MedicineUniversity of IowaIowa CityIA
| | - Pascal M. Jabbour
- Department of Neurological SurgerySidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPA
| | - Robert M. Starke
- Department of Neurological SurgeryMiller School of MedicineUniversity of MiamiFL
| | - Koji Hosaka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Adam J. Polifka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Brian L. Hoh
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Nohra Chalouhi
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
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4
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Maas AIR, Peul W, Thomé C. Surgical decompression in acute spinal cord injury: earlier is better. Lancet Neurol 2020; 20:84-86. [PMID: 33357515 DOI: 10.1016/s1474-4422(20)30478-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem 2650, Belgium.
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, Netherlands; Department of Neurosurgery, Haaglanden Medical Centre, The Hague, Netherlands
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
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5
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Gagalova KK, Leon Elizalde MA, Portales-Casamar E, Görges M. What You Need to Know Before Implementing a Clinical Research Data Warehouse: Comparative Review of Integrated Data Repositories in Health Care Institutions. JMIR Form Res 2020; 4:e17687. [PMID: 32852280 PMCID: PMC7484778 DOI: 10.2196/17687] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 06/09/2020] [Accepted: 07/17/2020] [Indexed: 12/23/2022] Open
Abstract
Background Integrated data repositories (IDRs), also referred to as clinical data warehouses, are platforms used for the integration of several data sources through specialized analytical tools that facilitate data processing and analysis. IDRs offer several opportunities for clinical data reuse, and the number of institutions implementing an IDR has grown steadily in the past decade. Objective The architectural choices of major IDRs are highly diverse and determining their differences can be overwhelming. This review aims to explore the underlying models and common features of IDRs, provide a high-level overview for those entering the field, and propose a set of guiding principles for small- to medium-sized health institutions embarking on IDR implementation. Methods We reviewed manuscripts published in peer-reviewed scientific literature between 2008 and 2020, and selected those that specifically describe IDR architectures. Of 255 shortlisted articles, we found 34 articles describing 29 different architectures. The different IDRs were analyzed for common features and classified according to their data processing and integration solution choices. Results Despite common trends in the selection of standard terminologies and data models, the IDRs examined showed heterogeneity in the underlying architecture design. We identified 4 common architecture models that use different approaches for data processing and integration. These different approaches were driven by a variety of features such as data sources, whether the IDR was for a single institution or a collaborative project, the intended primary data user, and purpose (research-only or including clinical or operational decision making). Conclusions IDR implementations are diverse and complex undertakings, which benefit from being preceded by an evaluation of requirements and definition of scope in the early planning stage. Factors such as data source diversity and intended users of the IDR influence data flow and synchronization, both of which are crucial factors in IDR architecture planning.
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Affiliation(s)
- Kristina K Gagalova
- Canada's Michael Smith Genome Sciences Centre, BC Cancer, Vancouver, BC, Canada.,Bioinformatics Graduate Program, University of British Columbia, Vancouver, BC, Canada.,Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - M Angelica Leon Elizalde
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Elodie Portales-Casamar
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Matthias Görges
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
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6
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Al-Mufti F, Dodson V, Roh D, Bauerschmidt A, Park S, Agarwal S, Meyers PM, Connolly ES, Claassen J, Schmidt JM. In Reply: White Blood Cell Count Improves Prediction of Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2020; 86:E579. [PMID: 32133532 DOI: 10.1093/neuros/nyaa040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurosurgery Westchester Medical Center New York Medical College Valhalla, New York.,Department of Neurology Westchester Medical Center New York Medical College Valhalla, New York
| | - Vincent Dodson
- Department of Neurosurgery Rutgers New Jersey Medical School Newark, New Jersey
| | - David Roh
- Department of Neurology Columbia University Medical Center New York, New York
| | | | - Soojin Park
- Department of Neurology Columbia University Medical Center New York, New York
| | - Sachin Agarwal
- Department of Neurology Columbia University Medical Center New York, New York
| | - Philip M Meyers
- Department of Neurology Columbia University Medical Center New York, New York.,Department of Neurosurgery Columbia University Medical Center New York, New York
| | - E Sander Connolly
- Department of Neurosurgery Columbia University Medical Center New York, New York
| | - Jan Claassen
- Department of Neurology Columbia University Medical Center New York, New York.,Department of Neurosurgery Columbia University Medical Center New York, New York
| | - J Michael Schmidt
- Department of Neurology Columbia University Medical Center New York, New York
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7
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Jaja BNR, Schweizer TA, Claassen J, Le Roux P, Mayer SA, Macdonald RL. The SAFARI Score to Assess the Risk of Convulsive Seizure During Admission for Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2019; 82:887-893. [PMID: 28973169 DOI: 10.1093/neuros/nyx334] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 05/17/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Seizure is a significant complication in patients under acute admission for aneurysmal SAH and could result in poor outcomes. Treatment strategies to optimize management will benefit from methods to better identify at-risk patients. OBJECTIVE To develop and validate a risk score for convulsive seizure during acute admission for SAH. METHODS A risk score was developed in 1500 patients from a single tertiary hospital and externally validated in 852 patients. Candidate predictors were identified by systematic review of the literature and were included in a backward stepwise logistic regression model with in-hospital seizure as a dependent variable. The risk score was assessed for discrimination using the area under the receiver operator characteristics curve (AUC) and for calibration using a goodness-of-fit test. RESULTS The SAFARI score, based on 4 items (age ≥ 60 yr, seizure occurrence before hospitalization, ruptured aneurysm in the anterior circulation, and hydrocephalus requiring cerebrospinal fluid diversion), had AUC = 0.77, 95% confidence interval (CI): 0.73-0.82 in the development cohort. The validation cohort had AUC = 0.65, 95% CI 0.56-0.73. A calibrated increase in the risk of seizure was noted with increasing SAFARI score points. CONCLUSION The SAFARI score is a simple tool that adequately stratified SAH patients according to their risk for seizure using a few readily derived predictor items. It may contribute to a more individualized management of seizure following SAH.
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Affiliation(s)
- Blessing N R Jaja
- Neuroscience Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Tom A Schweizer
- Department of Surgery, Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Jan Claassen
- Division of Critical Care Neurology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Peter Le Roux
- Thomas Jefferson University, Philadelphia, Pennsylvania.,Brain and Spine Center, Lankenau Medical Center, Wynnewood, Pennsylvania
| | | | - R Loch Macdonald
- Department of Surgery, Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada
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8
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Dijkland SA, Jaja BNR, van der Jagt M, Roozenbeek B, Vergouwen MDI, Suarez JI, Torner JC, Todd MM, van den Bergh WM, Saposnik G, Zumofen DW, Cusimano MD, Mayer SA, Lo BWY, Steyerberg EW, Dippel DWJ, Schweizer TA, Macdonald RL, Lingsma HF. Between-center and between-country differences in outcome after aneurysmal subarachnoid hemorrhage in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository. J Neurosurg 2019; 133:1132-1140. [PMID: 31443072 DOI: 10.3171/2019.5.jns19483] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Differences in clinical outcomes between centers and countries may reflect variation in patient characteristics, diagnostic and therapeutic policies, or quality of care. The purpose of this study was to investigate the presence and magnitude of between-center and between-country differences in outcome after aneurysmal subarachnoid hemorrhage (aSAH). METHODS The authors analyzed data from 5972 aSAH patients enrolled in randomized clinical trials of 3 different treatments from the Subarachnoid Hemorrhage International Trialists (SAHIT) repository, including data from 179 centers and 20 countries. They used random effects logistic regression adjusted for patient characteristics and timing of aneurysm treatment to estimate between-center and between-country differences in unfavorable outcome, defined as a Glasgow Outcome Scale score of 1-3 (severe disability, vegetative state, or death) or modified Rankin Scale score of 4-6 (moderately severe disability, severe disability, or death) at 3 months. Between-center and between-country differences were quantified with the median odds ratio (MOR), which can be interpreted as the ratio of odds of unfavorable outcome between a typical high-risk and a typical low-risk center or country. RESULTS The proportion of patients with unfavorable outcome was 27% (n = 1599). The authors found substantial between-center differences (MOR 1.26, 95% CI 1.16-1.52), which could not be explained by patient characteristics and timing of aneurysm treatment (adjusted MOR 1.21, 95% CI 1.11-1.44). They observed no between-country differences (adjusted MOR 1.13, 95% CI 1.00-1.40). CONCLUSIONS Clinical outcomes after aSAH differ between centers. These differences could not be explained by patient characteristics or timing of aneurysm treatment. Further research is needed to confirm the presence of differences in outcome after aSAH between hospitals in more recent data and to investigate potential causes.
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Affiliation(s)
| | - Blessing N R Jaja
- 2Division of Neurosurgery and
- 3Neuroscience Research Program, Li Ka Shing Knowledge Institute, and
- 4Institute of Medical Science and
| | | | - Bob Roozenbeek
- 6Neurology, and
- 7Radiology and Nuclear Medicine, Erasmus MC-University Medical Center, Rotterdam
| | - Mervyn D I Vergouwen
- 8Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jose I Suarez
- 9Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - James C Torner
- 10Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Michael M Todd
- 11Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Walter M van den Bergh
- 12Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen
| | - Gustavo Saposnik
- 3Neuroscience Research Program, Li Ka Shing Knowledge Institute, and
- 4Institute of Medical Science and
- 13Decision Neuroscience Unit, Division of Neurology, St. Michael's Hospital, University of Toronto
| | - Daniel W Zumofen
- 14Department of Neurosurgery and
- 15Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Michael D Cusimano
- 2Division of Neurosurgery and
- 3Neuroscience Research Program, Li Ka Shing Knowledge Institute, and
- 4Institute of Medical Science and
- 16Department of Surgery, University of Toronto, Toronto, Ontario
| | - Stephan A Mayer
- 17Department of Neurology, Henry Ford Health System, Detroit, Michigan; and
| | - Benjamin W Y Lo
- 18Departments of Neurology, Neurosurgery, and Critical Care, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Ewout W Steyerberg
- Departments of1Public Health
- 19Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden
| | | | - Tom A Schweizer
- 2Division of Neurosurgery and
- 3Neuroscience Research Program, Li Ka Shing Knowledge Institute, and
- 4Institute of Medical Science and
- 16Department of Surgery, University of Toronto, Toronto, Ontario
| | - R Loch Macdonald
- 2Division of Neurosurgery and
- 3Neuroscience Research Program, Li Ka Shing Knowledge Institute, and
- 4Institute of Medical Science and
- 16Department of Surgery, University of Toronto, Toronto, Ontario
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9
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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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11
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Roethlisberger M, Achermann R, Bawarjan S, Stienen MN, Fung C, D’Alonzo D, Maldaner N, Ferrari A, Corniola MV, Schöni D, Goldberg J, Valsecchi D, Robert T, Maduri R, Seule MA, Burkhardt JK, Marbacher S, Bijlenga P, Blackham KA, Bucher HC, Mariani L, Guzman R, Zumofen DW. Impact of Aneurysm Multiplicity on Treatment and Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2018; 84:E334-E344. [DOI: 10.1093/neuros/nyy331] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 06/21/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michel Roethlisberger
- Department of Neurosurgery, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Rita Achermann
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Schatlo Bawarjan
- Department of Neurosurgery, University Hospital Göttingen, Göttingen, Germany
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Donato D’Alonzo
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Andrea Ferrari
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marco V Corniola
- Department of Neurosurgery, Hopitaux Universitaires Genève, Geneva, Switzerland
| | - Daniel Schöni
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Daniele Valsecchi
- Department of Neurosurgery, Ospedale Civico di Lugano, Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Ospedale Civico di Lugano, Lugano, Switzerland
| | - Rodolfo Maduri
- Service of Neurosurgery, Department of Clinical Neurosciences, University Hospital of Lausanne, Lausanne, Switzerland
| | - Martin A Seule
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, NYU School of Medicine, NYU Langone Medical Center, New York, New York
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Philippe Bijlenga
- Department of Neurosurgery, Hopitaux Universitaires Genève, Geneva, Switzerland
| | - Kristine A Blackham
- Department of Radiology, Division of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurosurgery, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Radiology, Division of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
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12
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Germans MR, Jaja BNR, de Oliviera Manoel AL, Cohen AH, Macdonald RL. Sex differences in delayed cerebral ischemia after subarachnoid hemorrhage. J Neurosurg 2018; 129:458-464. [DOI: 10.3171/2017.3.jns162808] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVEIn this study the authors sought to investigate the sex differences in the risk of delayed cerebral ischemia (DCI), delayed cerebral infarction, and the role of hormonal status.METHODSTen studies included in the SAHIT (SAH International Trialists) repository were analyzed using a fitting logistic regression model. Heterogeneity between the studies was tested using I2 statistics, and the results were pooled using a random-effects model. Multivariable analysis was adjusted for the effects of neurological status and fixed effect of study. An additional model was examined in which women and men were split into groups according to an age cut point of 55 years, as a surrogate to define hormonal status.RESULTSA pooled cohort of 6713 patients was analyzed. The risk of DCI was statistically significantly higher in women than in men (OR 1.29, 95% CI 1.12–1.48); no difference was found with respect to cerebral infarction (OR 1.17, 95% CI 0.98–1.40). No difference was found in the risk of DCI when comparing women ≤ 55 and > 55 years (OR 0.87, 95% CI 0.74–1.02; p = 0.08) or when comparing men ≤ 55 and > 55 years (p = 0.38). Independent predictors of DCI were World Federation of Neurosurgical Societies (WFNS) grade, Fisher grade, age, and sex. Independent predictors of infarction included WFNS grade, Fisher grade, and aneurysm size.CONCLUSIONSFemale sex is associated with a higher risk of DCI. Sex differences may play a role in the pathogenesis of DCI but are not associated with menopausal status. The predictors of DCI and cerebral infarction were identified in a very large cohort and reflect experience from multiple institutions.
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Affiliation(s)
- Menno R. Germans
- 1Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | - R. Loch Macdonald
- 4Division of Neurosurgery, Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael’s Hospital; and
- 5Faculty of Medicine, University of Toronto, Ontario, Canada
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Roethlisberger M, Achermann R, Bawarjan S, Stienen MN, Fung C, D'Alonzo D, Maldaner N, Ferrari A, Corniola MV, Schöni D, Valsecchi D, Maduri R, Seule MA, Burkhardt JK, Marbacher S, Bijlenga P, Blackham KA, Bucher HC, Mariani L, Guzman R, Zumofen DW, Fandino J, Colluccia D, Arrighi M, Venier A, Kuhlen DE, Robert T, Reinert M, Weyerbrock A, Hlavica M, Fournier JY, Raabe A, Beck J, Bervini D, Schaller K, Daniel RT, Starnoni D, Messerer M, Levivier M, Keller E, Regli L, Bozinov O, Finkenstaedt S, Remonda L, Stippich C, Gralla J, Kulcsar Z, Mendes-Pereira V, Ahlborn P, Smoll NR, Rohde V, Tok S, Baumann F, Kothbauer K, Kerkeni H, Dan-Ura H, Landolt H, Mostaguir K, Gasche Y, Sarrafzadeh A, Hildebrandt G, Winkler K, Woernle C, Bernays R. Predictors of Occurrence and Anatomic Distribution of Multiple Aneurysms in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2018; 111:e199-e205. [DOI: 10.1016/j.wneu.2017.12.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 11/29/2022]
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Zumofen DW, Roethlisberger M, Achermann R, Bawarjan S, Stienen MN, Fung C, D'Alonzo D, Maldaner N, Ferrari A, Corniola MV, Schoeni D, Goldberg J, Valsecchi D, Robert T, Maduri R, Seule M, Burkhardt JK, Marbacher S, Bijlenga P, Blackham KA, Bucher HC, Mariani L, Guzman R. Factors associated with clinical and radiological status on admission in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2018; 41:1059-1069. [PMID: 29428981 DOI: 10.1007/s10143-018-0952-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/25/2018] [Accepted: 01/28/2018] [Indexed: 01/12/2023]
Abstract
Grading scales yield objective measure of the severity of aneurysmal subarachnoid hemorrhage and serve as to guide treatment decisions and for prognostication. The purpose of this cohort study was to determine what factors govern a patient's disease-specific admission scores in a representative Central European cohort. The Swiss Study of Subarachnoid Hemorrhage includes anonymized data from all tertiary referral centers serving subarachnoid hemorrhage patients in Switzerland. The 2009-2014 dataset was used to evaluate the impact of patient and aneurysm characteristics on the patients' status at admission using descriptive and multivariate regression analysis. The primary/co-primary endpoints were the GCS and the WFNS grade. The secondary endpoints were the Fisher grade, the presence of a thick cisternal or ventricular clot, the presence of a new focal neurological deficit or cranial nerve palsy, and the patient's intubation status. In our cohort of 1787 consecutive patients, increasing patient age by 10 years and low pre-ictal functional status (mRS 3-5) were inversely correlated with "high" GCS score (GCS ≥ 13) (OR 0.91, 95% CI 0.84-0.97 and OR 0.67, 95% CI 0.31-1.46), "low" WFNS grade (grade VI-V) (OR 1.21, 95% CI 1.04-1.20 and OR 1.47, 95% CI 0.66-3.27), and high Fisher grade (grade III-IV) (OR 1.08, 95% CI 1.00-1.17 and OR 1.54, 95% CI 0.55-4.32). Other independent predictors for the patients' clinical and radiological condition at admission were the ruptured aneurysms' location and its size. In sum, chronological age and pre-ictal functional status, as well as the ruptured aneurysm's location and size, determine the patients' clinical and radiological condition at admission to the tertiary referral hospital.
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Affiliation(s)
- Daniel W Zumofen
- Department of Neurosurgery, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland. .,Department of Radiology, Division of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland.
| | - Michel Roethlisberger
- Department of Neurosurgery, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Rita Achermann
- Department Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, CH-4031, Basel, Switzerland
| | - Schatlo Bawarjan
- Department of Neurosurgery, University Hospital Göttingen, Robert Koch Strasse 40, 37075, Göttingen, Germany
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Inselspital, University of Bern, Freiburgstrasse 16, CH-3010, Bern, Switzerland
| | - Donato D'Alonzo
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Aarau, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Andrea Ferrari
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St.Gallen, Switzerland
| | - Marco V Corniola
- Department of Neurosurgery, Hopitaux Universitaires Genève, Rue Gabrielle-Perret-Gentil 4, CH-1205, Geneva, Switzerland
| | - Daniel Schoeni
- Department of Neurosurgery, Inselspital, University of Bern, Freiburgstrasse 16, CH-3010, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, University of Bern, Freiburgstrasse 16, CH-3010, Bern, Switzerland
| | - Daniele Valsecchi
- Department of Neurosurgery, Ospedale Civico di Lugano, Via Tesserete 46, CH-6900, Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Ospedale Civico di Lugano, Via Tesserete 46, CH-6900, Lugano, Switzerland
| | - Rodolfo Maduri
- Service of Neurosurgery, Department of Clinical Neurosciences, University Hospital of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Martin Seule
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St.Gallen, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143-0112, USA
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Aarau, Switzerland
| | - Philippe Bijlenga
- Department of Neurosurgery, Hopitaux Universitaires Genève, Rue Gabrielle-Perret-Gentil 4, CH-1205, Geneva, Switzerland
| | - Kristine A Blackham
- Department of Radiology, Division of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Heiner C Bucher
- Department Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, CH-4031, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
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Seizures and Choice of Antiepileptic Drugs Following Subarachnoid Hemorrhage: A Review. Can J Neurol Sci 2017; 44:643-653. [DOI: 10.1017/cjn.2017.206] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractSeizures are important complications following a subarachnoid hemorrhage (SAH). The evidence for the use of antiepileptic drugs (AEDs) in treatment and prevention of those seizures is conflicting. The purpose of this review is to provide an up-to-date evidence summary of the incidence and outcomes of seizures following an SAH as well as the use of different AEDs post-SAH in order to evaluate the need for seizure prophylaxis, the choice of AEDs, and their dosing considerations in SAH patients. A literature search of PubMed, Medline, Embase, and the Cochrane Library was performed. A total of 37 studies were reviewed, mostly observational. Definitions of seizures in temporal relation to initial hemorrhage were variable. Similarly, the rates of seizures varied in the literature, ranging from 0 to 31%. Given the reported adverse outcomes associated with AED usage, seizure prophylaxis is not warranted. Levetiracetam appears to be better tolerated than phenytoin in SAH patients, though further research is needed. Higher initial dosing of levetiracetam might be required due to its enhanced clearance in SAH patients. In conclusion, there is a lack of quality evidence to definitively recommend the use of one AED over another. Further prospective research comparing the use of different AEDs in patients with an SAH is needed.
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Abstract
Subarachnoid haemorrhage is an uncommon and severe subtype of stroke affecting patients at a mean age of 55 years, leading to loss of many years of productive life. The rupture of an intracranial aneurysm is the underlining cause in 85% of cases. Survival from aneurysmal subarachnoid haemorrhage has increased by 17% in the past few decades, probably because of better diagnosis, early aneurysm repair, prescription of nimodipine, and advanced intensive care support. Nevertheless, survivors commonly have cognitive impairments, which in turn affect patients' daily functionality, working capacity, and quality of life. Additionally, those deficits are frequently accompanied by mood disorders, fatigue, and sleep disturbances. Management requires specialised neurological intensive care units and multidisciplinary clinical expertise, which is better provided in high-volume centres. Many clinical trials have been done, but only two interventions are shown to improve outcome. Challenges that remain relate to prevention of subarachnoid haemorrhage by improved screening and development of lower-risk methods to repair or stabilise aneurysms that have not yet ruptured. Multicentre cooperative efforts might increase the knowledge that can be gained from clinical trials, which is often limited by small studies with differing criteria and endpoints that are done in single centres. Outcome assessments that incorporate finer assessment of neurocognitive function and validated surrogate imaging or biomarkers for outcome could also help to advance the specialty.
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Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada; Labatt Family Centre of Excellence in Brain Injury and Trauma Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Tom A Schweizer
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada; Labatt Family Centre of Excellence in Brain Injury and Trauma Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
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Etminan N, Macdonald R. Management of aneurysmal subarachnoid hemorrhage. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:195-228. [DOI: 10.1016/b978-0-444-63600-3.00012-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Hänggi D, Etminan N, Macdonald RL, Steiger HJ, Mayer SA, Aldrich F, Diringer MN, Hoh BL, Mocco J, Strange P, Faleck HJ, Miller M. NEWTON: Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage. Neurocrit Care 2016; 23:274-84. [PMID: 25678453 DOI: 10.1007/s12028-015-0112-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. EG-1962 is a sustained-release microparticle formulation of nimodipine that has shown preclinical efficacy when administered intraventricularly or intracisternally to dogs with SAH, without evidence of toxicity at doses in the anticipated therapeutic range. Thus, we propose to administer EG-1962 to humans in order to assess safety and tolerability and determine a dose to investigate efficacy in subsequent clinical studies. METHODS We describe a Phase 1/2a multicenter, controlled, randomized, open-label, dose escalation study to determine the maximum tolerated dose (MTD) and assess the safety and tolerability of EG-1962 in patients with aSAH. The study will comprise two parts: a dose escalation period (Part 1) to determine the MTD of EG-1962 and a treatment period (Part 2) to assess the safety and tolerability of the selected dose of EG-1962. Patients with a ruptured saccular aneurysm treated by neurosurgical clipping or endovascular coiling will be considered for enrollment. Patients will be randomized to receive either EG-1962 (study drug: nimodipine microparticles) or oral nimodipine in the approved dose regimen (active control) within 60 h of aSAH. RESULTS Primary objectives are to determine the MTD and the safety and tolerability of the selected dose of intraventricular EG-1962 as compared to enteral nimodipine. The secondary objective is to determine release and distribution by measuring plasma and CSF concentrations of nimodipine. Exploratory objectives are to determine the incidence of delayed cerebral infarction on computed tomography, clinical features of delayed cerebral ischemia, angiographic vasospasm, and incidence of rescue therapy and clinical outcome. Clinical outcome will be determined at 90 days after aSAH using the extended Glasgow outcome scale, modified Rankin scale, Montreal cognitive assessment, telephone interview of cognitive status, and Barthel index. CONCLUSION Here, we describe a Phase 1/2a multicenter, controlled, randomized, open-label, dose escalation study to determine the MTD and assess the safety and tolerability of EG-1962 in patients with aSAH.
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Affiliation(s)
- Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225, Düsseldorf, Germany,
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Wan A, Jaja BNR, Schweizer TA, Macdonald RL. Clinical characteristics and outcome of aneurysmal subarachnoid hemorrhage with intracerebral hematoma. J Neurosurg 2016; 125:1344-1351. [PMID: 26918469 DOI: 10.3171/2015.10.jns151036] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Intracerebral hematoma (ICH) with subarachnoid hemorrhage (SAH) indicates a unique feature of intracranial aneurysm rupture since the aneurysm is in the subarachnoid space and separated from the brain by pia mater. Broad consensus is lacking regarding the concept that ultra-early treatment improves outcome. The aim of this study is to determine the associative factors for ICH, ascertain the prognostic value of ICH, and investigate how the timing of treatment relates to the outcome of SAH with concurrent ICH. METHODS The study data were pooled from the SAH International Trialists repository. Logistic regression was applied to study the associations of clinical and aneurysm characteristics with ICH. Proportional odds models and dominance analysis were applied to study the effect of ICH on 3-month outcome (Glasgow Outcome Scale) and investigate the effect of time from ictus to treatment on outcome. RESULTS Of the 5362 SAH patients analyzed, 1120 (21%) had concurrent ICH. In order of importance, neurological status, aneurysm location, aneurysm size, and patient ethnicity were significantly associated with ICH. Patients with ICH experienced poorer outcome than those without ICH (OR 1.58; 95% CI 1.37-1.82). Treatment within 6 hours of SAH was associated with poorer outcome than treatment thereafter (adjusted OR 1.67; 95% CI 1.04-2.69). Subgroup analysis with adjustment for ICH volume, location, and midline shift resulted in no association between time from ictus to treatment and outcome (OR 0.99; 95% CI 0.94-1.07). CONCLUSIONS The most important associative factor for ICH is neurological status on admission. The finding regarding the value of ultra-early treatment suggests the need to more robustly reevaluate the concept that hematoma evacuation of an ICH and repair of a ruptured aneurysm within 6 hours of ictus is the most optimal treatment path.
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Affiliation(s)
- Anthony Wan
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto; and Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada
| | - Blessing N R Jaja
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto; and Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada
| | - Tom A Schweizer
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto; and Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada
| | - R Loch Macdonald
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto; and Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada
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Jaja BNR, Lingsma H, Steyerberg EW, Schweizer TA, Thorpe KE, Macdonald RL. Neuroimaging characteristics of ruptured aneurysm as predictors of outcome after aneurysmal subarachnoid hemorrhage: pooled analyses of the SAHIT cohort. J Neurosurg 2015; 124:1703-11. [PMID: 26495952 DOI: 10.3171/2015.4.jns142753] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Neuroimaging characteristics of ruptured aneurysms are important to guide treatment selection, and they have been studied for their value as outcome predictors following aneurysmal subarachnoid hemorrhage (SAH). Despite multiple studies, the prognostic value of aneurysm diameter, location, and extravasated SAH clot on computed tomography scan remains debatable. The authors aimed to more precisely ascertain the relation of these factors to outcome. METHODS The data sets of studies included in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository were analyzed including data on ruptured aneurysm location and diameter (7 studies, n = 9125) and on subarachnoid clot graded on the Fisher scale (8 studies; n = 9452) for the relation to outcome on the Glasgow Outcome Scale (GOS) at 3 months. Prognostic strength was quantified by fitting proportional odds logistic regression models. Univariable odds ratios (ORs) were pooled across studies using random effects models. Multivariable analyses were adjusted for fixed effect of study, age, neurological status on admission, other neuroimaging factors, and treatment modality. The neuroimaging predictors were assessed for their added incremental predictive value measured as partial R(2). RESULTS Spline plots indicated outcomes were worse at extremes of aneurysm size, i.e., less than 4 or greater than 9 mm. In between, aneurysm size had no effect on outcome (OR 1.03, 95% CI 0.98-1.09 for 9 mm vs 4 mm, i.e., 75th vs 25th percentile), except in those who were treated conservatively (OR 1.17, 95% CI 1.02-1.35). Compared with anterior cerebral artery aneurysms, posterior circulation aneurysms tended to result in slightly poorer outcome in patients who underwent endovascular coil embolization (OR 1.13, 95% CI 0.82-1.57) or surgical clipping (OR 1.32, 95% CI 1.10-1.57); the relation was statistically significant only in the latter. Fisher CT subarachnoid clot burden was related to outcome in a gradient manner. Each of the studied predictors accounted for less than 1% of the explained variance in outcome. CONCLUSIONS This study, which is based on the largest cohort of patients so far analyzed, has more precisely determined the prognostic value of the studied neuroimaging factors. Treatment choice has strong influence on the prognostic effect of aneurysm size and location. These findings should guide the development of reliable prognostic models and inform the design and analysis of future prospective studies, including clinical trials.
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Affiliation(s)
- Blessing N R Jaja
- Division of Neurosurgery and.,Li Ka Shing Knowledge Institute, St. Michael's Hospital;,Institute of Medical Science
| | - Hester Lingsma
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, The Netherlands
| | - Tom A Schweizer
- Division of Neurosurgery and.,Li Ka Shing Knowledge Institute, St. Michael's Hospital;,Institute of Medical Science
| | - Kevin E Thorpe
- Li Ka Shing Knowledge Institute, St. Michael's Hospital;,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; and
| | - R Loch Macdonald
- Division of Neurosurgery and.,Li Ka Shing Knowledge Institute, St. Michael's Hospital;,Institute of Medical Science
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Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Ontario, Canada; and Department of Surgery, University of Toronto, Ontario, Canada.
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de Oliveira Manoel AL, Jaja BN, Germans MR, Yan H, Qian W, Kouzmina E, Marotta TR, Turkel-Parrella D, Schweizer TA, Macdonald RL. The VASOGRADE: A Simple Grading Scale for Prediction of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. Stroke 2015; 46:1826-31. [PMID: 25977276 DOI: 10.1161/strokeaha.115.008728] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 04/07/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Patients are classically at risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage. We validated a grading scale-the VASOGRADE-for prediction of DCI. METHODS We used data of 3 phase II randomized clinical trials and a single hospital series to assess the relationship between the VASOGRADE and DCI. The VASOGRADE derived from previously published risk charts and consists of 3 categories: VASOGRADE-Green (modified Fisher scale 1 or 2 and World Federation of Neurosurgical Societies scale [WFNS] 1 or 2); VASOGRADE-Yellow (modified Fisher 3 or 4 and WFNS 1-3); and VASOGRADE-Red (WFNS 4 or 5, irrespective of modified Fisher grade). The relation between the VASOGRADE and DCI was assessed by logistic regression models. The predictive accuracy of the VASOGRADE was assessed by receiver operating characteristics curve and calibration plots. RESULTS In a cohort of 746 patients, the VASOGRADE significantly predicted DCI (P<0.001). The VASOGRADE-Yellow had a tendency for increased risk for DCI (odds ratio [OR], 1.31; 95% CI, 0.77-2.23) when compared with VASOGRADE-Green; those with VASOGRADE-Red had a 3-fold higher risk of DCI (OR, 3.19; 95% CI, 2.07-4.50). Studies were not a significant confounding factor between the VASOGRADE and DCI. The VASOGRADE had an adequate discrimination for prediction of DCI (area under the receiver operating characteristics curve=0.63) and good calibration. CONCLUSIONS The VASOGRADE results validated previously published risk charts in a large and diverse sample of subarachnoid hemorrhage patients, which allows DCI risk stratification on presentation after subarachnoid hemorrhage. It could help to select patients at high risk of DCI, as well as standardize treatment protocols and research studies.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.).
| | - Blessing N Jaja
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Menno R Germans
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Han Yan
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Winnie Qian
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Ekaterina Kouzmina
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Tom R Marotta
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - David Turkel-Parrella
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Tom A Schweizer
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - R Loch Macdonald
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
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Aneurysmal Subarachnoid Hemorrhage—Status Quo and Perspective. Transl Stroke Res 2015; 6:167-70. [DOI: 10.1007/s12975-015-0398-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 03/31/2015] [Indexed: 11/26/2022]
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Jaja BNR, Lingsma H, Schweizer TA, Thorpe KE, Steyerberg EW, Macdonald RL. Prognostic value of premorbid hypertension and neurological status in aneurysmal subarachnoid hemorrhage: pooled analyses of individual patient data in the SAHIT repository. J Neurosurg 2015; 122:644-52. [PMID: 25554825 DOI: 10.3171/2014.10.jns132694] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECT The literature has conflicting reports about the prognostic value of premorbid hypertension and neurological status in aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to investigate the prognostic value of premorbid hypertension and neurological status in the SAH International Trialists repository. METHODS Patient-level meta-analyses were conducted to investigate univariate associations between premorbid hypertension (6 studies; n = 7249), admission neurological status measured on the World Federation of Neurosurgical Societies (WFNS) scale (10 studies; n = 10,869), and 3-month Glasgow Outcome Scale (GOS) score. Multivariable analyses were performed to sequentially adjust for the effects of age, CT clot burden, aneurysm location, aneurysm size, and modality of aneurysm repair. Prognostic associations were estimated across the ordered categories of the GOS using proportional odds models. Nagelkerke's R(2) statistic was used to quantify the added prognostic value of hypertension and neurological status beyond those of the adjustment factors. RESULTS Premorbid hypertension was independently associated with poor outcome, with an unadjusted pooled odds ratio (OR) of 1.73 (95% confidence interval [CI] 1.50-2.00) and an adjusted OR of 1.38 (95% CI 1.25-1.53). Patients with a premorbid history of hypertension had higher rates of cardiovascular and renal comorbidities, poorer neurological status (p ≤ 0.001), and higher odds of neurological complications including cerebral infarctions, hydrocephalus, rebleeding, and delayed ischemic neurological deficits. Worsening neurological status was strongly independently associated with poor outcome, including WFNS Grades II (OR 1.85, 95% CI 1.68-2.03), III (OR 3.85, 95% CI 3.32-4.47), IV (OR 5.58, 95% CI 4.91-6.35), and V (OR 14.18, 95% CI 12.20-16.49). Neurological status had substantial added predictive value greater than the combined value of other prognostic factors (R(2) increase > 10%), while the added predictive value of hypertension was marginal (R(2) increase < 0.5%). CONCLUSIONS This study confirmed the strong prognostic effect of neurological status as measured on the WFNS scale and the independent but weak prognostic effect of premorbid hypertension. The effect of premorbid hypertension could involve multifactorial mechanisms, including an increase in the severity of initial bleeding, the rate of comorbid events, and neurological complications.
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