Electroencephalography, Hospital Complications, and Longitudinal Outcomes After Subarachnoid Hemorrhage

A Novel Mechanism Linking Melatonin, Ferroptosis and Microglia Polarization via the Circodz3/HuR Axis in Subarachnoid Hemorrhage

A subarachnoid hemorrhage (SAH) is life-threatening bleeding into the subarachnoid space that causes brain damage. Growing evidence has suggested that melatonin provides neuroprotection following SAH. Exploring the mechanisms underlying melatonin-mediated neuroprotection contributes to its clinical application in SAH. The plasma and cerebrospinal fluid (CSF) were collected from SAH patients, and SAH mice were established via pre-chiasmatic injection. Circodz3 expression, levels of IL-1β and TNF-α, brain water content, neurological and beam-waling scores were determined. Ferroptosis was evaluated by analyzing levels of iron, lipid ROS, MDA, and GSH. The colocalization of circodz3 and Iba-1 was analyzed by immunofluorescence staining. Interaction of circodz3 and HuR was determined with RNA pull-down and RNA immunoprecipitation assays. Herein, we found that circodz3 was highly abundant in SAH patients and mice. Colocalization of circodz3 and Iba-1 in the left hemisphere of SAH mice suggested the implication of circodz3 in regulating microglia activation following SAH. Melatonin alleviated brain edema, neurological impairment, and microglia activation and inhibited circodz3 expression in SAH mice. Moreover, melatonin inhibited M1 polarization, oxidative stress and ferroptosis and restrained circodz3 expression in primary microglia following SAH. These effects were abrogated by circodz3 overexpression. Circodz3 knockdown inhibited ferroptosis and M1 polarization of BV2 microglia after SAH. Circodz3 interacted with HuR to facilitate β-Trcp1-mediated ubiquitination and degradation, thus restraining the expression of SLC7A11 and GPX4. Collectively, melatonin exerted neuroprotection following SAH via inhibiting ferroptosis and M1 polarization through the circodz3/HuR axis. Our study suggests potential application of melatonin in the treatment of SAH.

Outcomes Measures in Subarachnoid Hemorrhage Research

Despite advancements in acute management, morbidity rates for subarachnoid hemorrhage (SAH) remain high. Therefore, it is imperative to utilize standardized outcome scales in SAH research for evaluating new therapies effectively. This review offers a comprehensive overview of prevalent scales and clinical outcomes used in SAH assessment, accompanied by recommendations for their application and prognostic accuracy. Standardized terminology and diagnostic criteria should be employed when reporting pathophysiological outcomes such as symptomatic vasospasm and delayed cerebral ischemia. Furthermore, integrating clinical severity scales like the World Federation of Neurosurgical Societies scale and modified Fisher score into clinical trials is advised to evaluate their prognostic significance, despite their limited correlation with outcomes. The modified Rankin score is widely used for assessing functional outcomes, while the Glasgow outcome scale-extended version is suitable for broader social and behavioral evaluations. Avoiding score dichotomization is crucial to retain valuable information. Cognitive and behavioral outcomes, though frequently affected in patients with favorable neurological outcomes, are often overlooked during follow-up outpatient visits, despite their significant impact on quality of life. Comprehensive neuropsychological evaluations conducted by trained professionals are recommended for characterizing cognitive function, with the Montreal Cognitive Assessment serving as a viable screening tool. Additionally, integrating psychological inventories like the Beck Depression and Anxiety Inventory, along with quality-of-life scales such as the Stroke-Specific Quality of Life Scale, can effectively assess behavioral and quality of life outcomes in SAH studies.

Utility and rationale for continuous EEG monitoring: a primer for the general intensivist

This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.

Prevalence of clinical electroencephalography findings in stroke patients with delirium

OBJECTIVE

Delirium is an acute cognitive disorder associated with multiple electroencephalographic (EEG) abnormalities in non-neurological patients, though specific EEG characteristics in patients with stroke remain unclear. We aimed to compare the prevalence of EEG abnormalities in stroke patients during delirium episodes with periods that did not correspond to delirium.

METHODS

We retrospectively analyzed clinical EEG reports for stroke patients who received daily delirium assessments as part of a prospective study. We compared the prevalence of EEG features corresponding to patient-days with vs. without delirium, including focal and generalized slowing, and focal and generalized epileptiform abnormalities (EAs).

RESULTS

Among 58 patients who received EEGs, there were 192 days of both EEG and delirium monitoring (88% [n = 169] corresponding to delirium). Generalized slowing was significantly more prevalent on days with vs. without delirium (96% vs. 57%, p = 0.03), as were bilateral or generalized EAs (38% vs. 13%, p = 0.03). In contrast, focal slowing (53% vs. 74%, p = 0.11) and focal EAs were less prevalent on days with delirium (38% vs. 48%, p = 0.37), though these differences were not statistically significant.

CONCLUSIONS

We found a higher prevalence of generalized but not focal EEG abnormalities in stroke patients with delirium.

SIGNIFICANCE

These findings may reinforce the diffuse nature of delirium-associated encephalopathy, even in patients with discrete structural lesions.

Stroke Unit as an alternative to Intensive Care Unit for initial hospital admission of low-grade non-aneurysmal subarachnoid haemorrhage: A safety and cost-minimisation analysis

INTRODUCTION

Stroke Units (SU) have been suggested as an alternative to Intensive Care units (ICU) for initial admission of low-grade non-aneurysmal spontaneous subarachnoid haemorrhage (naSAH). We hypothesised that the incidence of in-hospital complications and long-term clinical outcomes in low-grade naSAH patients would be comparable in both settings, and that a cost-minimisation analysis would favour the use of SU.

PATIENTS AND METHODS

Retrospective, single-centre study at a third-level stroke-referral hospital, including low-grade spontaneous naSAH patients with WFNS 1-2. Primary outcomes were death and functional status at 3 months. Secondary outcomes were incidence of in-hospital major neurological and systemic complications. Additionally, a cost-minimisation analysis was conducted to estimate the average cost savings that could be achieved with the most efficient approach.

RESULTS

Out of 96 naSAH patients, 30 (31%) were initially admitted to ICU and 66 (69%) to SU. Both groups had similar demographic and radiological features except for a higher proportion of WFNS 2 in ICU subgroup. There were no statistically significant differences between ICU and SU-managed subgroups in death rate (2 (7%) and 1 (2%), respectively), functional outcome at 90 days (28 (93%) and 61 (92%) modified Rankin Scale 0-2) or neurological and systemic in-hospital complications. Cost-minimisation analysis demonstrated significant monetary savings favouring the SU strategy.

DISCUSSION AND CONCLUSION

Initial admission to the SU appears to be a safe and cost-effective alternative to the ICU for low-grade naSAH patients, with comparable clinical outcomes and a reduction of hospitalisation-related costs. Prospective multicenter randomised studies are encouraged to further evaluate this approach.

An Epidemiological Investigation on Patients with Non-traumatic Subarachnoid Hemorrhage from 2010 to 2020

Objective

Subarachnoid hemorrhage (SAH) is still considered a life-threatening medical condition with a high mortality rate, particularly in developing countries. Thus, the present study aimed to investigate the angiographic findings of non-traumatic or spontaneous SAH.

Methods

This retrospective cohort study included 642 health records of patients with non-traumatic SAH over a 10-year period, from 2010 to 2020. The required data, including demographic information, aneurysm type, size, location, disease severity classification, and secondary complications, were extracted.

Results

The study included 642 patients, with 262 (40.8%) being male. The mean age of the participants was 54.72±13.51 years. The most prevalent type of aneurysm was saccular (89.1%), while serpentine (0.2%) and dissecting saccular (0.2%) aneurysms had the least prevalence. The most frequently involved arteries were the anterior communicating artery (ACoA; 38%), internal carotid artery (ICA; 27.6%), and middle cerebral artery (MCA; 13.4%). There was a significant correlation between sex and aneurysms occurring at ACoA and ICA (p< 0.0001), and ACoA - A1 (p=0.02). Patient age and sex were also significantly correlated with one another (p<0.0001). There was no statistically significant correlation between sex, aneurysm size, Glasgow coma scale (GCS), and modified Rankin scale (MRS).

Conclusion

Based on our findings, the presence of aneurysms at ACoA, ACoA - A1, and ICA should be thoroughly ruled out in patients with severe headaches of sudden onset, particularly male patients of younger ages.

The Role of Nursing Care in the Management of Patients with Traumatic Subarachnoid Hemorrhage

Traumatic subarachnoid hemorrhage (tSAH) is a critical condition that requires comprehensive management to optimize patient outcomes. Nursing care plays a key role in the overall management of patients with tSAH via various aspects of care, including neurological assessment, monitoring, intervention, and education. In this review, we aim to evaluate the significant contributions of nursing care in managing patients with tSAH. Nurses perform initial neurological assessments, including the glasgow coma scale, pupil reactivity, vital signs, and sensory-motor evaluations. These assessments provide valuable information for early identification of deteriorating neurological status and prompt intervention. Additionally, nurses closely monitor intracranial pressure (ICP), cerebral perfusion pressure, and other hemodynamic parameters, assisting in the prevention and timely detection of secondary brain injury. For example, some strategies to manage ICP include elevating the head of the bed, maintaining adequate oxygenation and ventilation, administering proper medications, and ensuring fluid and electrolyte balance. Also, through careful monitoring, early recognition, and appropriate preventive measures, nursing care could prevent complications, including infections, deep vein thrombosis, and pressure ulcers. Furthermore, nursing care extends beyond physical management and encompasses psychosocial support for patients and their families. Nurses establish therapeutic relationships, providing emotional support, education, and counseling to alleviate anxiety, address concerns, and facilitate coping mechanisms. Education regarding medication management, lifestyle modifications, and the importance of regular follow-up enhances patient compliance and promotes long-term recovery.

Physiological Monitoring in Patients with Acute Brain Injury: A Multimodal Approach

Neurocritical care management of acute brain injury (ABI) is focused on identification, prevention, and management of secondary brain injury (SBI). Physiologic monitoring of the brain and other organ systems has a role to predict patient recovery or deterioration, guide individualized therapeutic interventions, and measure response to treatment, with the goal of improving patient outcomes. In this review, we detail how specific physiologic markers of brain injury and neuromonitoring tools are integrated and used in ABI patients to develop therapeutic approaches to prevent SBI.

Bispectral index monitoring to detect delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

PURPOSE

Evaluate the bispectral index (BIS) monitoring to detect delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH).

MATERIALS AND METHODS

A single-center prospective study in patients with aSAH. BIS monitoring was recorded during 25-120 min in two periods, within the initial 72 h (BIS1) and between days 4 and 6 (BIS2) from admission. The median for each exported BIS parameter was analyzed. Transcranial Doppler (TCD) sonography was simultaneously performed with BIS1 (TCD1) and BIS2 (TCD2) monitoring. A multivariate logistic regression model was built to identify the variables associated with DCI.

RESULTS

Sixty-four patients were included and 16 (25%) developed DCI. During BIS2 monitoring, significant differences were found in BIS value (left, p = 0.01; right, p = 0.009), 95% spectral edge frequency (left and right, p = 0.04), and total power (left and right, p = 0.04). In multivariable analysis, vasospasm on TCD2 (OR 42.8 [95% CI 3.1-573]; p = 0.005), a median BIS2 value <85 in one or both sides (OR 6.2 [95% CI 1.28-30]; p = 0.023), and age (OR 1.08 [95% CI 1.00-1.17]; p = 0.04) were associated with the development of DCI.

CONCLUSIONS

BIS value is the most useful BIS parameter for detecting DCI after aSAH. Pending further validation, BIS monitoring might be even more accurate than TCD.

Utilization of EEG for Monitoring in Subarachnoid hemorrhage Recovery

Seizures and delayed cerebral ischemia following subarachnoid hemorrhage are associated with significant morbidity and mortality. In this article, we briefly review subarachnoid hemorrhage, its complications, and the current literature on information gained from EEG monitoring in subarachnoid hemorrhage. We review when EEG should be used implemented in the multi-modal monitoring of patients with subarachnoid hemorrhage. Finally, we discuss the recent advances and future directions in the field.

Neutrophil Extracellular Traps and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage

IMPORTANCE

Myeloperoxidase (MPO)-DNA complexes, biomarkers of neutrophil extracellular traps (NETs), have been associated with arterial and venous thrombosis. Their role in aneurysmal subarachnoid hemorrhage (aSAH) is unknown.

OBJECTIVES

To assess whether serum MPO-DNA complexes are present in patients with aSAH and whether they are associated with delayed cerebral ischemia (DCI).

DESIGN SETTING AND PARTICIPANTS

Post-hoc analysis of a prospective, observational single-center study, with de novo serum biomarker measurements in consecutive patients with aSAH between July 2018 and September 2020, admitted to a tertiary care neuroscience ICU.

MAIN OUTCOMES AND MEASURES

We analyzed serum obtained at admission and hospital day 4 for concentrations of MPO-DNA complexes. The primary outcome was DCI, defined as new infarction on brain CT. The secondary outcome was clinical vasospasm, a composite of clinical and transcranial Doppler parameters. We used Wilcoxon signed-rank-test to assess for differences between paired measures.

RESULTS

Among 100 patients with spontaneous subarachnoid hemorrhage, mean age 59 years (sd ± 13 yr), 55% women, 78 had confirmed aSAH. Among these, 29 (37%) developed DCI. MPO-DNA complexes were detected in all samples. The median MPO-DNA level was 33 ng/mL (interquartile range [IQR], 18-43 ng/mL) at admission, and 22 ng/mL (IQR, 11-31 ng/mL) on day 4 (unpaired test; p = 0.015). We found a significant reduction in MPO-DNA levels from admission to day 4 in patients with DCI (paired test; p = 0.036) but not in those without DCI (p = 0.17). There was a similar reduction in MPO-DNA levels between admission and day 4 in patients with (p = 0.006) but not in those without clinical vasospasm (p = 0.47).

CONCLUSIONS AND RELEVANCE

This is the first study to detect the NET biomarkers MPO-DNA complexes in peripheral serum of patients with aSAH and to associate them with DCI. A pronounced reduction in MPO-DNA levels might serve as an early marker of DCI. This diagnostic potential of MPO-DNA complexes and their role as potential therapeutic targets in aSAH should be explored further.