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Bömers JP, Holm A, Kazantzi S, Edvinsson L, Mathiesen TI, Haanes KA. Protein kinase C-inhibition reduces critical weight loss and improves functional outcome after experimental subarachnoid haemorrhage. J Stroke Cerebrovasc Dis 2024; 33:107728. [PMID: 38643942 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107728] [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: 05/17/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/23/2024] Open
Abstract
OBJECTIVES Subarachnoid haemorrhage (SAH) carries a high burden of morbidity and mortality. One in three patients develop vasospasm, which is associated with Delayed Cerebral Ischemia. The pathophysiology includes vasoconstrictor receptor upregulation in cerebral arteries. The protein kinase C - inhibitor RO-31-7549 reduces the expression of several vasoconstrictor receptors and normalizes cerebral blood flow in experimental SAH but functional and behavioural effects are unknown. This study was undertaken to analyse functional outcomes up to 14 days after experimental SAH. MATERIALS AND METHODS 54 male rats were randomised to experimental SAH or sham, using the pre-chiasmatic, single injection model, and subsequent treatment or vehicle. 42 remained for final analysis. The animals were euthanized on day 14 or when reaching a humane endpoint. The primary endpoint was overall survival, defined as either spontaneous mortality or when reaching a predefined humane endpoint. The secondary outcomes were differences in the rotating pole test, weight, open field test, novel object recognition and qPCR of selected inflammatory markers. RESULTS In the vehicle group 6/15 rats reached the humane endpoint of >20 % weight loss compared to 1/14 in the treatment group. This resulted in a significant reduced risk of early euthanasia due to >20 % weight loss of HR 0.15 (0.03-0.66, p = 0.04). Furthermore, the treatment group did significantly better on the rotating pole test, RR 0.64 (0.47-0.91, p = 0.02). CONCLUSION RO-31-7549 improved outcomes in terms >20 % weight loss and rotating pole performance after experimental SAH and could be investigated.
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Affiliation(s)
- Jesper P Bömers
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.
| | - Anja Holm
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Center for RNA Medicine, Aalborg University, Copenhagen, Denmark
| | - Spyridoula Kazantzi
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Lars Edvinsson
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Tiit I Mathiesen
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kristian A Haanes
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Biology, University of Copenhagen, Copenhagen, Denmark
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van der Harst JJ, Elting JWJ, Hijlkema J, Veeger NJGM, van Donkelaar CE, van Dijk JMC, Uyttenboogaart M. Diagnostic value of transcranial doppler to predict delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage : To predict delayed cerebral ischemia. Acta Neurochir (Wien) 2024; 166:278. [PMID: 38949680 PMCID: PMC11217085 DOI: 10.1007/s00701-024-06164-1] [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: 04/06/2024] [Accepted: 06/07/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Transcranial Doppler (TCD) is a technique to assess blood flow velocity in the cerebral arteries. TCD is frequently used to monitor aneurysmal subarachnoid hemorrhage (aSAH) patients. This study compares TCD-criteria for vasospasm and its association with Delayed Cerebral Ischemia (DCI). An overall score based on flow velocities of various intracranial arteries was developed and evaluated. METHODS A retrospective diagnostic accuracy study was conducted between 1998 and 2017 with 621 patients included. Mean flow velocity (MFV) of the cerebral artery was measured between 2-5 days and between 6-9 days after ictus. Cutoff values from the literature, new cutoff values, and a new composite score (Combined Severity Score) were used to predict DCI. Sensitivity, specificity, and area under the curve (AUC) were determined, and logistic regression analysis was performed. RESULTS The Combined Severity Score showed an AUC 0.64 (95%CI 0.56-.71) at days 2-5, with sensitivity 0.53 and specificity 0.74. The Combined Severity Score had an adjusted Odds Ratio of 3.41 (95CI 1.86-6.32) for DCI. MCA-measurements yielded the highest AUC to detect DCI at day 2-5: AUC 0.65 (95%CI 0.58-0.73). Optimal cutoff MFV of 83 cm/s for MCA resulted in sensitivity 0.73 and specificity 0.50 at days 2-5. CONCLUSION TCD-monitoring of aSAH patients may be a valuable strategy for DCI risk stratification. Lower cutoff values can be used in the early phase after the ictus (day 2-5) than are commonly used now. The Combined Severity Score incorporating all major cerebral arteries may provide a meaningful contribution to interpreting TCD measurements.
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Affiliation(s)
- J Joep van der Harst
- Departments of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Jan Willem J Elting
- Departments of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Johanna Hijlkema
- Departments of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nic J G M Veeger
- Department of Epidemiology, Uversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carlina E van Donkelaar
- Department of Neurosurger, Uversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Department of Neurosurger, Uversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Departments of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Shah KA, White TG, Teron I, Turpin J, Dehdashti AR, Temes RE, Black K, Woo HH. Quantitative magnetic resonance angiography as an alternative imaging technique in the assessment of cerebral vasospasm after subarachnoid hemorrhage. Interv Neuroradiol 2024; 30:271-279. [PMID: 36357992 PMCID: PMC11095350 DOI: 10.1177/15910199221138167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 10/25/2022] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION The major mechanism of morbidity of delayed cerebral ischemia after subarachnoid hemorrhage (SAH) is considered to be severe vasospasm. Quantitative MRA (QMRA) provides direct measurements of vessel-specific volumetric blood flow and may permit a clinically relevant assessment of the risk of ischemia secondary to cerebral vasospasm. PURPOSE To evaluate the utility of QMRA as an alternative imaging technique for the assessment of cerebral vasospasm after SAH. METHODS QMRA volumetric flow rates of the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) were compared with vessel diameters on catheter-based angiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of QMRA for detecting cerebral vasospasm was determined by receiver-operating characteristic curves. Spearman correlation coefficients were calculated for QMRA flow versus angiographic vessel diameter. RESULTS Sixty-six vessels (10 patients) were evaluated with QMRA and catheter-based angiography. The median percent QMRA flow of all vessels with angiographic vasospasm (55.0%, IQR 34.3-71.6%) was significantly lower than the median percent QMRA flow of vessels without vasospasm (91.4%, IQR 81.4-100.4%) (p < 0.001). Angiographic vasospasm reduced QMRA-assessed flow by 23 ± 5 (p = 0.018), 95 ± 12 (p = 0.042), and 16 ± 4 mL/min (p = 0.153) in the ACA, MCA, and PCA, respectively, compared to vessels without angiographic vasospasm. The sensitivity, specificity, PPV, and NPV of QMRA for the discrimination of cerebral vasospasm was 84%, 72%, 84%, and 72%, respectively, for angiographic vasospasm >25% and 91%, 60%, 87%, and 69%, respectively, for angiographic vasospasm >50%. The Spearman correlation indicated a significant association between QMRA flows and vessel diameters (rs = 0.71, p < 0.001). CONCLUSION Reduction in QMRA flow correlates with angiographic vessel narrowing and may be useful as a non-invasive imaging modality for the detection of cerebral vasospasm after SAH.
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Affiliation(s)
- Kevin A Shah
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Timothy G White
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Ina Teron
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Richard E Temes
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Karen Black
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Wendel C, Oberhauser C, Schiff J, Henkes H, Ganslandt O. Stellate Ganglion Block and Intraarterial Spasmolysis in Patients with Cerebral Vasospasm: A Retrospective Cohort Study. Neurocrit Care 2024; 40:603-611. [PMID: 37498456 PMCID: PMC10959776 DOI: 10.1007/s12028-023-01762-w] [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: 12/29/2022] [Accepted: 05/17/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND In patients with symptomatic cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage who do not respond to medical therapy, urgent treatment escalation has been suggested to be beneficial for brain tissue at risk. In our routine clinical care setting, we implemented stellate ganglion block (SGB) as a rescue therapy with subsequent escalation to intraarterial spasmolysis (IAS) with milrinone for refractory CV. METHODS In this retrospective analysis from 2012 to 2021, patients with CV following aneurysmal subarachnoid hemorrhage who received an SGB or IAS were identified. Patients were assessed through neurological examination and transcranial Doppler. Rescue therapy was performed in patients with mean cerebral blood flow velocity (CBFV) ≥ 120 cm/s and persistent neurological deterioration/intubation under induced hypertension. Patients were reassessed after therapy and the following day. The Glasgow Outcome Scale was assessed at discharge and 6-month follow-up. RESULTS A total of 82 patients (mean age 50.16 years) with 184 areas treated with SGB and/or IAS met the inclusion criteria; 109 nonaffected areas were extracted as controls. The mean CBFV decrease in the middle cerebral artery on the following day was - 30.1 (± 45.2) cm/s with SGB and - 31.5 (± 45.2) cm/s with IAS. Mixed linear regression proved the significance of the treatment categories; other fixed effects (sex, age, aneurysm treatment modality [clipping or coiling], World Federation of Neurological Surgeons score, and Fisher score) were insignificant. In logistic regression, the presence of cerebral infarction on imaging before discharge from the intensive care unit (34/82) was significantly associated with unfavorable outcomes (Glasgow Outcome Scale ≤ 3) at follow-up. CONCLUSIONS Stellate ganglion block and IAS decreased CBFV the following 24 h in patients with CV. We suggest SGB alone for patients with mild symptomatic CV (CBFV < 180 cm/s), while subsequent escalation to IAS proved to be beneficial in patients with refractory CV and severe CBFV elevation (CBFV ≥ 180 cm/s).
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Affiliation(s)
- Christopher Wendel
- Neurosurgical Clinic, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Chair of Public Health and Health Services Research, Ludwig-Maximilians-University, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Cornelia Oberhauser
- Institute for Medical Information Processing, Biometry, and Epidemiology, Chair of Public Health and Health Services Research, Ludwig-Maximilians-University, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Jan Schiff
- Department of Anesthesiology and Operative Intensive Care Medicine, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
- Department of Neurosurgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Topcu A, Ozkul A, Yilmaz A, Yi HJ, Shin DS, Kim B. The impact of collateral status on cerebral vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2023; 25:288-296. [PMID: 37232069 PMCID: PMC10555627 DOI: 10.7461/jcen.2023.e2022.11.005] [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: 11/16/2022] [Revised: 04/23/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE Cerebral collateral circulation may affect subarachnoid hemorrhage (SAH) induced cerebral vasospasm and delayed cerebral ischemia. In this study our aim was to investigate the relationship between collateral status, vasospasm and delayed cerebral ischemia (DCI) in both aneurysmal and nonaneurysmal SAH. METHODS Patients diagnosed as SAH with and without aneurysm were included and their data investigated retrospectively. After the patients diagnosed as SAH according to cerebral computed tomography (CT)/magnetic resonance imaging (MRI), they underwent cerebral angiography to check for cerebral aneurysm. The diagnosis of DCI was made according to the neurological examination and control CT/MRI. All the patients had their control cerebral angiography on days 7 to 10 in order to assess vasospasm and also collateral circulation. The American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) Collateral Flow Grading System was modified to measure collateral circulation. RESULTS A total of 59 patients data were analyzed. Patients with aneurysmal SAH had higher Fisher scores and DCI was more common. Although there was no statistically significant difference between the patients with and without DCI in terms of demographics and mortality, patients with DCI had worse collateral circulation and more severe vasospasm. These patients had higher Fisher scores and more cerebral aneurysm overall. CONCLUSIONS According to our data, patients with higher Fisher scores, more severe vasospasm, and poor cerebral collateral circulation may experience DCI more frequently. Additionally aneurysmal SAH had higher Fisher scores and DCI was seen more common. To improve the clinical results for SAH patients, we believe that physicians should be aware of the DCI risk factors.
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Affiliation(s)
- Abdullah Topcu
- Department of Neurosurgery, Adnan Menderes University Faculty of Medicine, Aydın, Tükiye
| | - Ayca Ozkul
- Department of Neurology, Adnan Menderes University Faculty of Medicine, Aydın, Tükiye
| | - Ali Yilmaz
- Department of Neurosurgery, Adnan Menderes University Faculty of Medicine, Aydın, Tükiye
| | - Ho Jun Yi
- Department of Neurosurgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Dong Seong Shin
- Department of Neurosurgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - BumTae Kim
- Department of Neurosurgery, Soonchunhyang University College of Medicine, Bucheon, Korea
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Palmisciano P, Hoz SS, Johnson MD, Forbes JA, Prestigiacomo CJ, Zuccarello M, Andaluz N. External Validation of an Extreme Gradient Boosting Model for Prediction of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 175:e108-e114. [PMID: 36914029 DOI: 10.1016/j.wneu.2023.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) may significantly worsen the functional status of patients with aneurysmal subarachnoid hemorrhage (aSAH). Several authors have designed predictive models for early identification of patients at risk of post-aSAH DCI. In this study, we externally validate an extreme gradient boosting (EGB) forecasting model for post-aSAH DCI prediction. METHODS A 9-year institutional retrospective review of patients with aSAH was performed. Patients were included if they underwent surgical or endovascular treatment and had available follow-up data. DCI was diagnosed as new-onset neurologic deficits at 4-12 days after aneurysm rupture, defined as worsening Glasgow Coma Scale score for ≥2 points, and new ischemic infarcts at imaging. RESULTS We collected 267 patients with aSAH. At admission, median Hunt-Hess score was 2 (range, 1-5), median Fisher score 3 (range, 1-4), and median modified Fisher score 3 (range, 1-4). One-hundred and forty-five patients underwent external ventricular drainage placement for hydrocephalus (54.3%). The ruptured aneurysms were treated with clipping (64%), coiling (34.8%), and stent-assisted coiling (1.1%). Fifty-eight patients (21.7%) were diagnosed with clinical DCI and 82 (30.7%) with asymptomatic imaging vasospasm. The EGB classifier correctly predicted 19 cases of DCI (7.1%) and 154 cases of no-DCI (57.7%), achieving sensitivity of 32.76% and specificity of 73.68%. The calculated F1 score and accuracy were 0.288% and 64.8%, respectively. CONCLUSIONS We validated that the EGB model is a potential assistant tool to predict post-aSAH DCI in clinical practice, finding moderate-high specificity but low sensitivity. Future research should investigate the underlying pathophysiology of DCI to allow the development of high-performing forecasting models.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Samer S Hoz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mark D Johnson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Yang R, Wang M, Dong Q, Zhou X. Transcranial Doppler versus CT angiography: a comparative analysis for the diagnosis of ischaemic cerebrovascular disease. Clin Radiol 2023; 78:e350-e357. [PMID: 36746722 DOI: 10.1016/j.crad.2022.12.014] [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: 08/26/2022] [Revised: 11/23/2022] [Accepted: 12/22/2022] [Indexed: 01/14/2023]
Abstract
AIMS To compare the sensitivity, specificity, accuracy, and clinical usefulness of transcranial Doppler (TCD) ultrasound against computed tomography angiography (CTA) for the diagnosis of ischaemic cerebrovascular disease. METHODS A total of 1,183 sites (vascular segments) of 169 patients who had been diagnosed with cerebrovascular disease using digital subtraction angiography (DSA) were evaluated by CTA and TCD for the diagnosis of the arterial lesions. RESULTS Lesions were identified in 509 sites and 674 sites did not have lesions according to the DSA examination. Each individual site had higher sensitivity, specificity, and accuracy for TCD than those for CTA, respectively. For all sites, TCD had higher true-positive (p=0.0029) and -negative (p=0.0151) values and fewer false-positive and -negative (p<0.0001 for both) values than those of CTA. The sensitivity, specificity, and accuracy of CTA for all sites to detect lesions were 77%, 88%, and 84%, respectively. The same parameters for TCD were 94%, 97%, and 95%, respectively. The beneficial scores for CTA and TCD to detect lesions were 0-0.795 diagnostic confidence and 0-0.91 diagnostic confidence, respectively. Beneficial scores >0.795 and >0.91 indicated a risk of underdiagnosis of lesions at CTA and TCD, respectively. CONCLUSIONS Compared with DSA (reference standard) and CTA, the study underscores the use of TCD in cerebrovascular pathology.
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Affiliation(s)
- R Yang
- Department of Neurological Function, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu, 222001, China
| | - M Wang
- Department of Neurological Function, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu, 222001, China
| | - Q Dong
- Department of Neurological Function, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu, 222001, China
| | - X Zhou
- Department of Neurology, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu, 222001, China.
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Liu X, Zhang X, Ma T, Li M, Zhang L, Li S, Zeng M, Kass IS, Peng Y. Risk factors for postoperative thrombosis-related complications in patients undergoing malignant brain tumor resection: a retrospective cohort study. Front Neurol 2023; 14:1108596. [PMID: 37144008 PMCID: PMC10151791 DOI: 10.3389/fneur.2023.1108596] [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: 11/26/2022] [Accepted: 03/27/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction Patients with malignant brain tumors frequently exhibit hypercoagulation and are at a high risk of postoperative thrombosis-related complications. However, the risk factors for postoperative thrombosis-related complications remain unclear. Methods In this retrospective, observational study, we consecutively enrolled elective patients undergoing resection of malignant brain tumors from 26 November 2018 to 30 September 2021. The primary objective of the study was to identify risk factors for a composite of three major adverse events including postoperative lower limb deep venous thrombosis, pulmonary embolism, and cerebral ischemia. Results A total of 456 patients were enrolled in this study, where 112 (24.6%) patients had postoperative thrombosis-related complications, 84 (18.4%) with lower limb deep venous thrombosis, 0 (0.0%) with pulmonary embolism, and 42 (9.2%) with cerebral ischemia. In a multivariate model, age more than 60 years (OR: 3.98, 95% CI: 2.30-6.88, P < 0.001), preoperative abnormal APTT (OR: 2.81, 95% CI: 1.06-7.42, P = 0.037), operation duration longer than 5 h (OR: 2.36, 95% CI: 1.34-4.16, P = 0.003), and admission to ICU (OR: 2.49, 95% CI: 1.21-5.12, P = 0.013) were independent risk factors of the postoperative deep vein thrombosis. Intraoperative plasma transfusion (OR: 6.85, 95% CI: 2.73-17.18, P < 0.001) was associated with significantly increased odds of deep vein thrombosis. Conclusion Patients with craniocerebral malignant tumors have a high incidence of postoperative thrombosis-related complications. There is an increase in the odds of postoperative lower limb deep venous thrombosis in patients; over 60 years old, with preoperative abnormal APTT, undergoing surgeries longer than 5-h, admission to ICU, or receiving intraoperative plasma infusion. Fresh frozen plasma infusion should be used more cautiously, especially in patients with a high risk of thrombosis.
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Affiliation(s)
- Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Muhan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liyong Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ira S. Kass
- Anesthesiology and Physiology and Pharmacology Departments, State University of New York Downstate Health Sciences University, New York, NY, United States
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Yuming Peng
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Ramasubramanian B, Reddy VS, Chellappan V, Ramakrishna S. Emerging Materials, Wearables, and Diagnostic Advancements in Therapeutic Treatment of Brain Diseases. BIOSENSORS 2022; 12:1176. [PMID: 36551143 PMCID: PMC9775999 DOI: 10.3390/bios12121176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 06/17/2023]
Abstract
Among the most critical health issues, brain illnesses, such as neurodegenerative conditions and tumors, lower quality of life and have a significant economic impact. Implantable technology and nano-drug carriers have enormous promise for cerebral brain activity sensing and regulated therapeutic application in the treatment and detection of brain illnesses. Flexible materials are chosen for implantable devices because they help reduce biomechanical mismatch between the implanted device and brain tissue. Additionally, implanted biodegradable devices might lessen any autoimmune negative effects. The onerous subsequent operation for removing the implanted device is further lessened with biodegradability. This review expands on current developments in diagnostic technologies such as magnetic resonance imaging, computed tomography, mass spectroscopy, infrared spectroscopy, angiography, and electroencephalogram while providing an overview of prevalent brain diseases. As far as we are aware, there hasn't been a single review article that addresses all the prevalent brain illnesses. The reviewer also looks into the prospects for the future and offers suggestions for the direction of future developments in the treatment of brain diseases.
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Affiliation(s)
- Brindha Ramasubramanian
- Department of Mechanical Engineering, Center for Nanofibers & Nanotechnology, National University of Singapore, Singapore 117574, Singapore
- Institute of Materials Research and Engineering (IMRE), Agency for Science, Technology and Research (A*STAR), #08-03, 2 Fusionopolis Way, Innovis, Singapore 138634, Singapore
| | - Vundrala Sumedha Reddy
- Department of Mechanical Engineering, Center for Nanofibers & Nanotechnology, National University of Singapore, Singapore 117574, Singapore
| | - Vijila Chellappan
- Institute of Materials Research and Engineering (IMRE), Agency for Science, Technology and Research (A*STAR), #08-03, 2 Fusionopolis Way, Innovis, Singapore 138634, Singapore
| | - Seeram Ramakrishna
- Department of Mechanical Engineering, Center for Nanofibers & Nanotechnology, National University of Singapore, Singapore 117574, Singapore
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Abstract
Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA.
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
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Tjerkstra MA, Verbaan D, Coert BA, Post R, van den Berg R, Coutinho JM, Horn J, Vandertop WP. Large practice variations in diagnosis and treatment of delayed cerebral ischemia after subarachnoid hemorrhage. World Neurosurg 2022; 160:e412-e420. [PMID: 35033694 DOI: 10.1016/j.wneu.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) contributes to poor outcomes after subarachnoid hemorrhage (SAH). The pathophysiology of DCI is not fully understood, which has hindered the adoption of a uniform definition. Furthermore, a reliable diagnostic test and an effective evidence-based treatment are lacking. This could lead to variations in care. METHODS A web-based survey on the variations in the definition, diagnosis, and treatment of DCI was designed and sent to 314 intensivists, neurologists, and neurosurgeons of all 9 hospitals in the Netherlands who care for patients with SAH. The responders were categorized into physicians responsible for the coordination of SAH care and those who were not. For questions on the definition and diagnosis, only the responses from the coordinating physicians were evaluated. For the treatment questions, all the responses were evaluated. RESULTS The response rate was 34% (106 of 314). All 9 hospitals were represented. Of the responses, 27 did not provide answers for the definition, diagnosis, or treatment questions; 79 responses were used for analysis. Signs of vasospasm were required by 21 of the 47 coordinating physicians (44%) when considering DCI. Of the 47 coordinating physicians, 24 (51%) did not use a diagnostic test results for a positive diagnosis of DCI. When patients were discharged within 21 days, 33 of the 73 responders (45%) did not provide a prescription for nimodipine continuation. Finally, all but one hospital had treated DCI with hypertension induction. CONCLUSIONS We found large variations in the definition, diagnosis, and treatment of DCI in the Netherlands. In the absence of evidence-based treatment, standardization of management seems warranted in an effort to optimize DCI care.
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Affiliation(s)
- Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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12
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Alexopoulos G, Zhang J, Karampelas I, Khan M, Quadri N, Patel M, Patel N, Almajali M, Mattei TA, Kemp J, Coppens J, Mercier P. Applied forecasting for delayed cerebral ischemia prediction post subarachnoid hemorrhage: Methodological fallacies. INFORMATICS IN MEDICINE UNLOCKED 2022. [DOI: 10.1016/j.imu.2021.100817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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13
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Majewska P, Hara S, Gulati S, Solheim O. Association between transcranial Doppler vasospasm and functional outcome after subarachnoid hemorrhage. Brain Circ 2021; 7:271-276. [PMID: 35071844 PMCID: PMC8757509 DOI: 10.4103/bc.bc_63_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/18/2021] [Accepted: 11/11/2021] [Indexed: 12/02/2022] Open
Abstract
AIM OF THE STUDY: This study aimed to investigate the association between transcranial Doppler (TCD) vasospasm and patient outcome and to assess the predictive factors for developing TCD vasospasm after subarachnoid hemorrhage (SAH). MATERIALS AND METHODS: This retrospective observational study included adult patients with nontraumatic SAH. Patient characteristics and TCD values were recorded retrospectively from patient records. Data on maxTCD (maximal TCD value recorded on any side between day 1 and day 14) as well as Δ TCD (maximal difference between mean velocity measured on days 1–3 and days 4–14 on any side) were calculated. The modified Rankin Score was recorded from electronic patient notes at discharge and 3, 6, and 12 months after ictus. The effect of TCD vasospasm, maxTCD, and Δ TCD on the clinical outcome was investigated. Potential predictive factors for developing TCD vasospasm were assessed. The association between the same factors and maxTCD and Δ TCD were explored. RESULTS: One hundred and thirty-eight patients were included in the study. Higher age was associated with a lower risk of developing TCD vasospasm (odds ratio: 0.952, 95% confidence interval: 0.924–0.982, P = 0.002). Fisher grade was a predictor of developing TCD vasospasm (P = 0.05). Age was negatively correlated with maxTCD (R = −0.47, P = 0.01). There was no statistically significant difference in patient outcome at hospital discharge and at 3, 6, and 12 months between patients with and without TCD vasospasm. Higher maxTCD and Δ TCD were associated with a worse clinical outcome at 3 months after SAH ictus. CONCLUSIONS: The clinical benefit of routine TCD assessments in SAH patients remains uncertain.
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Affiliation(s)
- Paulina Majewska
- Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
| | - Sozaburo Hara
- Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
| | - Sasha Gulati
- Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
| | - Ole Solheim
- Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
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14
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Schembri M, Verbaan D, Emmer BJ, Coert BA, Majoie CBLM, Vandertop WP, van den Berg R. Cerebral circulation time on DSA during endovascular treatment in WFNS grade I aneurysmal SAH patients-a predictor of DCI? Neuroradiology 2021; 63:2131-2138. [PMID: 34263336 DOI: 10.1007/s00234-021-02749-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Delayed cerebral ischemia (DCI) remains a contributor to poor outcome following aneurysmal subarachnoid hemorrhage (aSAH). We evaluated cerebral circulation time (CCT) on digital subtraction angiography (DSA) during endovascular treatment (EVT) in WFNS grade I aSAH patients as a predictor of DCI. METHODS Of 135 consecutive WNFS grade I aSAH patients, 90 were included. Age, gender, time of DSA from ictus (< 72 h or > 72 h), Fisher scale, severe vasospasm, development of DCI, EVD-dependent hydrocephalus, re-bleeding, and procedural complications were recorded. CCT was calculated retrospectively from multiphase DSA. Association with DCI was established through univariate and, subsequently, multivariable logistic regression. An optimal threshold value was identified using ROC curve analysis. Patient groups defined by threshold CCT value, DCI, and, subsequently, time of DSA from ictus were analyzed using χ2 and Fisher's exact test. RESULTS CCT was the only significant factor in the multivariable logistic regression for the outcome development of DCI (OR/second increase in CCT = 1.46 [95% CI 1.14-1.86, p = .003]). When CCT was dichotomized at 8.5 s, the odds ratio for developing DCI was 7.12 (95% CI 1.93-26.34, p = .003) for CCT > 8.5 s compared with < 8.5 s. There was a significant difference for DCI in all patient groups dichotomized by CCT < 8.5 s and > 8.5 s (all patients, p = .001; patients imaged before and after 72 h of ictus, p = .024 and p = .034, respectively). CONCLUSION A CCT > 8.5 s on DSA during EVT in WFNS grade I aSAH patients is associated with an increased risk of developing DCI and may aid in the management of high-risk patients.
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Affiliation(s)
- Mark Schembri
- Department of Neuroradiology, Amsterdam University Medical Centers (Location AMC), Meibergdreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands.
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (Location AMC), Meibergdreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands
| | - Bart J Emmer
- Department of Neuroradiology, Amsterdam University Medical Centers (Location AMC), Meibergdreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (Location AMC), Meibergdreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands
| | - Charles B L M Majoie
- Department of Neuroradiology, Amsterdam University Medical Centers (Location AMC), Meibergdreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (Location AMC), Meibergdreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands
| | - René van den Berg
- Department of Neuroradiology, Amsterdam University Medical Centers (Location AMC), Meibergdreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands
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15
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Rass V, Helbok R. How to diagnose delayed cerebral ischaemia and symptomatic vasospasm and prevent cerebral infarction in patients with subarachnoid haemorrhage. Curr Opin Crit Care 2021; 27:103-114. [PMID: 33405414 DOI: 10.1097/mcc.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischaemia (DCI) complicates the clinical course of patients with subarachnoid haemorrhage (SAH) in 20--30% and substantially worsens outcome. In this review, we describe a multimodal diagnostic approach based on underlying mechanisms of DCI and provide treatment options with a special focus on the most recently published literature. RECENT FINDINGS Symptomatic vasospasm refers to clinical deterioration in the presence of vasospasm whereas DCI constitutes multiple causes. Pathophysiologic mechanisms underlying DCI range beyond large vessel vasospasm from neuroinflammation, to microthromboembolism, impaired cerebral autoregulation, cortical spreading depolarizations and many others. The current definition of DCI can be challenged by these mechanisms. We propose a pragmatic approach using a combination of clinical examination, cerebral ultrasonography, neuroimaging modalities and multimodal neuromonitoring to trigger therapeutic interventions in the presence of DCI. In addition to prophylactic nimodipine and management principles to improve oxygen delivery and decrease the brain metabolic demand, other specific interventions include permissive hypertension, intra-arterial application of calcium channel blockers and in selected patients angioplasty. SUMMARY The complex pathophysiology underlying DCI urges for a multimodal diagnostic approach triggering targeted interventions. Novel treatment concepts still have to be proven in large trials.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria
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16
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Liu H, Xu Q, Li A. Nomogram for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage in the Chinese population. J Stroke Cerebrovasc Dis 2020; 29:105005. [PMID: 32807421 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Delayed cerebral ischemia is a serious complication of aneurysmal subarachnoid hemorrhage with debilitating and fatal consequences. Lack of well-established risk factors impedes early identification of high-risk patients with delayed cerebral ischemia. A nomogram provides personalized, evidence-based, and accurate risk estimation. To offset the lack of a predictive tool, we developed a nomogram to predict delayed cerebral ischemia before performing surgical interventions for aneurysmal subarachnoid hemorrhage to aid surgical decision-making. METHODS We retrospectively collected data from 887 consecutive eligible Chinese patients who underwent surgical clipping or endovascular coiling for aneurysmal subarachnoid hemorrhage. Patients who previously underwent surgery formed the training cohort (n = 621) for nomogram development; those who underwent surgery later formed the validation cohort (n = 266) to confirm the performance of the model. A multivariate logistic regression analysis identified the independent risk factors associated with delayed cerebral ischemia, which were then incorporated into the nomogram. RESULTS Delayed cerebral ischemia was identified in 158/621 patients (25.4%) in the training cohort and in 66/266 patients (24.8%) in the validation cohort. Preoperative factors associated with delayed cerebral ischemia were age > 65 years, modified Fisher grade of 3-4, ruptured aneurysm in the anterior circulation, Hunt-Hess grade of 4-5, high blood pressure on admission, and plasma homocysteine level ≥ 10 μmol/L. Incorporating these six factors in the nomogram achieved efficient concordance indices of 0.73 (95% confidence interval, 0.68-0.77) and 0.65 (95% confidence interval, 0.57-0.72) in predicting delayed cerebral ischemia in the training and validation cohorts, respectively. CONCLUSIONS Our model can help determine an individual's risk of developing delayed cerebral ischemia in the Chinese population, and thereby, facilitate reasonable treatment-related decision-making.
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Affiliation(s)
- Haonan Liu
- Department of Neurosurgery, Lianyungang Clinical College of Nanjing Medical University (The First People's Hospital of Lianyungang), 182 Tongguan North Road, Lianyungang 222002, China
| | - Qian Xu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Aimin Li
- Department of Neurosurgery, Lianyungang Clinical College of Nanjing Medical University (The First People's Hospital of Lianyungang), 182 Tongguan North Road, Lianyungang 222002, China.
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17
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Chang JJ, Triano M, Corbin MJ, Desale S, Liu AH, Felbaum DR, Mai JC, Armonda RA, Aulisi EF. Transcranial Doppler velocity and associations with delayed cerebral ischemia in aneurysmal subarachnoid Hemorrhage. J Neurol Sci 2020; 415:116934. [DOI: 10.1016/j.jns.2020.116934] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/15/2020] [Accepted: 05/17/2020] [Indexed: 10/24/2022]
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