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Sasaki T, Naraoka M, Shimamura N, Takemura A, Hasegawa S, Akasaka K, Ohkuma H. Factors Affecting Outcomes of Poor-Grade Subarachnoid Hemorrhage. World Neurosurg 2024; 185:e516-e522. [PMID: 38382759 DOI: 10.1016/j.wneu.2024.02.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE Poor-grade subarachnoid hemorrhage (SAH) accounts for 20% of all SAH and is associated with poor outcomes. The first step in improving outcomes is to analyze the factors that contribute to poor outcomes. METHODS This was a multicenter, retrospective, observational, cohort study. Data fields included demographic, clinical, radiological, and outcome data for all spontaneous patients with SAH treated at 4 hospitals in Aomori Prefecture in Japan. Patients with modified Rankin Scale score 0-2 at discharge were defined as the good outcome group, and those with modified Rankin Scale score 3-6 were defined as the poor outcome group, and comparisons were made between the 2 groups. RESULTS There were 329 eligible patients with poor-grade SAH, 41 with good outcome group, and 288 with poor outcome group. On multivariate analysis of the outcome, conservative treatment (P < 0.001), Fisher group 4 (P < 0.007), age ≥65 years (P = 0.011), and Hunt and Kosnik grade V on admission (P = 0.021) were significant factors contributing to a poor outcome. CONCLUSIONS Nonelderly patients who are not in grade V and Fisher group 4 should undergo aneurysm treatment as soon as possible because they are more likely to have a good outcome, whereas elderly patients in grade V and Fisher group 4 are unlikely to benefit from aneurysm treatment at present. The development of a treatment for early brain injury may be important to improve the outcomes of patients with poor-grade SAH.
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Affiliation(s)
- Takao Sasaki
- Department of Neurosurgery, Hirosaki University, Hirosaki, Aomori, Japan.
| | - Masato Naraoka
- Department of Emergency, Disaster and General Medicine, Hirosaki University, Hirosaki, Aomori, Japan
| | - Norihito Shimamura
- Department of Neurosurgery, Hirosaki General Medical Center, Hirosaki, Aomori, Japan
| | - Atsuto Takemura
- Department of Neurosurgery, General Southern Tohoku Hospital, Iwanuma, Miyagi, Japan
| | - Seiko Hasegawa
- Department of Emergency, Disaster and General Medicine, Hirosaki University, Hirosaki, Aomori, Japan
| | - Kennichi Akasaka
- Department of Neurosurgery, Towada City Central Hospital, Towada, Aomori, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki General Medical Center, Hirosaki, Aomori, Japan
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Hofmann BB, Fischer I, Neyazi M, Karadag C, Donaldson DM, Abusabha Y, Muhammad S, Beseoglu K, Cornelius JF, Hänggi D. Revisiting the WFNS Score: Native Computed Tomography Imaging Improves Identification of Patients With "False Poor Grade" Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2024; 94:515-523. [PMID: 37823661 DOI: 10.1227/neu.0000000000002715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/13/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In patients suffering from aneurysmal subarachnoid hemorrhage (aSAH), the optimal time to determine the World Federation of Neurosurgical Societies (WFNS) score remains controversial because of possible confounding factors. Goals of this study were (1) to analyze the most sensitive timepoint to determine the WFNS score in patients with aSAH and (2) to evaluate the impact of initial native computed tomography (CT) imaging on reducing the mismatch of "false poor grade" patients. METHODS We retrospectively analyzed daily WFNS scores from admission until day 7 in 535 aSAH patients and evaluated their predictive value for the modified Rankin Scale at discharge and 6 months postbleeding. Patients with an initial WFNS score of IV-V who showed improvement to a WFNS score of I-II within the first 7 days (even short-term) were defined as "false poor grade" patients. We tried to identify the "false poor grade" patients using parameters of the initial native CT imaging. RESULTS Later determination of the WFNS score (day 1 vs 7; pseudo-R 2 = 0.13 vs 0.21) increasingly improved its predictive value for neurological outcome at discharge ( P < .001). We identified 39 "false poor grade" patients who had significantly better outcomes than "real poor grade" patients (N = 220) (modified Rankin Scale-discharge: 0-2, 56% vs 1%, P < .001; 3-5: 41% vs 56%, P = .12; 6: 3% vs 43%, P < .001). "False poor grade" patients differed significantly in initial CT parameters. A predictive model called "initial CT WFNS" ( ICT WFNS) was developed, incorporating SEBES, Hijdra score, and LeRoux score (sensitivity = 0.95, specificity = 0.84, accuracy = 0.859, F1 = 0.673). ICT WFNS scores of ≤4.6 classified patients as "false poor grade." CONCLUSION The initial WFNS score may misclassify a subgroup of patients with aSAH as poor grade, which can be avoided by later determination of the WFNS score, at days 3-4 losing its usefulness. Alternatively, the initial WFNS score can be improved in its predictive value, especially in poor-grade patients, using criteria from the initial native CT imaging, such as the Hijdra, LeRoux, and Subarachnoid Hemorrhage Early Brain Edema score, combined in the ICT WFNS score with even higher predictive power.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki , Finland
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf , Germany
| | - Daniel Hänggi
- Department of Neurosurgery, International Neuroscience Institute, Hannover , Germany
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Hofmann BB, Donaldson DM, Fischer I, Karadag C, Neyazi M, Piedade GS, Abusabha Y, Muhammad S, Rubbert C, Hänggi D, Beseoglu K. Blood Pressure Affects the Early CT Perfusion Imaging in Patients with aSAH Reflecting Early Disturbed Autoregulation. Neurocrit Care 2023; 39:125-134. [PMID: 36802010 PMCID: PMC10499698 DOI: 10.1007/s12028-023-01683-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/26/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early computed tomography perfusion (CTP) is frequently used to predict delayed cerebral ischemia following aneurysmatic subarachnoid hemorrhage (aSAH). However, the influence of blood pressure on CTP is currently controversial (HIMALAIA trial), which differs from our clinical observations. Therefore, we aimed to investigate the influence of blood pressure on early CTP imaging in patients with aSAH. METHODS We retrospectively analyzed the mean transit time (MTT) of early CTP imaging within 24 h after bleeding prior to aneurysm occlusion with respect to blood pressure shortly before or after the examination in 134 patients. We correlated the cerebral blood flow with the cerebral perfusion pressure in the case of patients with intracranial pressure measurement. We performed a subgroup analysis of good-grade (World Federation of Neurosurgical Societies [WFNS] I-III), poor-grade (WFNS IV-V), and solely WFNS grade V aSAH patients. RESULTS Mean arterial pressure (MAP) significantly correlated inversely with the mean MTT in early CTP imaging (R = - 0.18, 95% confidence interval [CI] - 0.34 to - 0.01, p = 0.042). Lower mean blood pressure was significantly associated with a higher mean MTT. Subgroup analysis revealed an increasing inverse correlation when comparing WFNS I-III (R = - 0.08, 95% CI - 0.31 to 0.16, p = 0.53) patients with WFNS IV-V (R = - 0.2, 95% CI - 0.42 to 0.05, p = 0.12) patients, without reaching statistical significance. However, if only patients with WFNS V are considered, a significant and even stronger correlation between MAP and MTT (R = - 0.4, 95% CI - 0.65 to 0.07, p = 0.02) is observed. In patients with intracranial pressure monitoring, a stronger dependency of cerebral blood flow on cerebral perfusion pressure is observed for poor-grade patients compared with good-grade patients. CONCLUSIONS The inverse correlation between MAP and MTT in early CTP imaging, increasing with the severity of aSAH, suggests an increasing disturbance of cerebral autoregulation with the severity of early brain injury. Our results emphasize the importance of maintaining physiological blood pressure values in the early phase of aSAH and preventing hypotension, especially in patients with poor-grade aSAH.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Daniel M Donaldson
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Guilherme S Piedade
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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de Winkel J, Cras TY, Dammers R, van Doormaal PJ, van der Jagt M, Dippel DWJ, Lingsma HF, Roozenbeek B. Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. BMC Neurol 2022; 22:239. [PMID: 35773634 PMCID: PMC9245240 DOI: 10.1186/s12883-022-02734-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment, although recent studies suggest that functional outcome following early aneurysm treatment has improved. We aimed to systematically review and meta-analyze early predictors of functional outcome in poor-grade aSAH patients. METHODS: We included studies investigating the association of early predictors and functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H-H) grade IV-V. Studies had to use multivariable regression analysis to estimate independent predictor effects of favorable functional outcome measured with the Glasgow Outcome Scale or modified Rankin Scale. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with random effects models. RESULTS: We included 27 studies with 3287 patients. The likelihood of favorable outcome increased with WFNS grade or H-H grade IV versus V (aOR 2.9, 95% CI 1.9-4.3), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0-5.3), and intact pupillary light reflex (aOR 2.9, 95% CI 1.6-5.1), and decreased with older age (aOR 0.7, 95% CI 0.5-1.0, per decade), increasing modified Fisher grade (aOR 0.4, 95% CI 0.3-0.5, per grade), and presence of intracerebral hematoma on admission imaging (aOR 0.4, 95% CI 0.2-0.8). CONCLUSIONS We present a summary of early predictors of functional outcome in poor-grade aSAH patients that can help to discriminate between patients with favorable and with unfavorable prognosis and may aid in selecting patients for early aneurysm treatment.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Tim Y Cras
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Wen L, Zhou L, Wu Q, Tang X, Ge J, Zhou X, Zhang X. Early Microcirculatory Hemodynamic Changes Are Correlated With Functional Outcomes at Discharge in Patients With Aneurysmal SAH. Front Neurol 2022; 12:793411. [PMID: 35126294 PMCID: PMC8811302 DOI: 10.3389/fneur.2021.793411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose The technique of color-coding blood flow analysis was used to explore the correlation between the microcirculatory hemodynamic changes on digital subtraction angiography (DSA) images in patients with aneurysmal subarachnoid hemorrhage (SAH) at the early stage and functional outcomes at discharge. Methods Data of 119 patients who underwent DSA examination due to SAH were retrospectively analyzed. The following hemodynamic parameters of the four region of interests (ROIs) [an ophthalmic segment of the internal carotid artery (ICA), frontal and parietal lobe, and superior sagittal sinus] were analyzed: the time-to-peak (TTP), the area under the curve (AUC), the full width at half maximum (FWHM), mean transit time (MTT), and circulation time. Multifactor regression analysis was performed to explore the correlation between the hemodynamic parameters and functional outcomes in patients at discharge. Results Of 119 patients with SAH, good and poor outcomes were found in 83 (69.7%) and 36 (30.3%) patients, respectively. The hemodynamic parameters including the FWHM, relative TTP (rTTP), and circulation time were significantly correlated with the Hunt–Hess grade (p < 0.005, p = 0.03, and p < 0.005) and the World Federation of Neurological Societies Scale grade (p < 0.005, p = 0.02, and p = 0.01). The FWHM was significantly prolonged with the increase of modified Fisher grade (p = 0.02). The multifactor analysis showed that the FWHM [odds ratio (OR) 17.56, 95% CI: 1.13–272.03, p = 0.04] was an independent risk factor predicting the functional outcomes in patients at discharge. Conclusion The technique of color-coding blood flow analysis could be suitable for the qualified evaluation of disease conditions at an early stage of SAH as well as the prediction of outcomes.
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Affiliation(s)
- Lili Wen
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Longjiang Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaoyu Tang
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jiajia Ge
- Advanced Therapies, Siemens Healthineers Ltd., Shanghai, China
| | - Xiaoming Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
- *Correspondence: Xin Zhang
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Neutrophils mediate early cerebral cortical hypoperfusion in a murine model of subarachnoid haemorrhage. Sci Rep 2019; 9:8460. [PMID: 31186479 PMCID: PMC6560094 DOI: 10.1038/s41598-019-44906-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/28/2019] [Indexed: 02/07/2023] Open
Abstract
Cerebral hypoperfusion in the first hours after subarachnoid haemorrhage (SAH) is a major determinant of poor neurological outcome. However, the underlying pathophysiology is only partly understood. Here we induced neutropenia in C57BL/6N mice by anti-Ly6G antibody injection, induced SAH by endovascular filament perforation, and analysed cerebral cortical perfusion with laser SPECKLE contrast imaging to investigate the role of neutrophils in mediating cerebral hypoperfusion during the first 24 h post-SAH. SAH induction significantly increased the intracranial pressure (ICP), and significantly reduced the cerebral perfusion pressure (CPP). At 3 h after SAH, ICP had returned to baseline and CPP was similar between SAH and sham mice. However, in SAH mice with normal neutrophil counts cortical hypoperfusion persisted. Conversely, despite similar CPP, cortical perfusion was significantly higher at 3 h after SAH in mice with neutropenia. The levels of 8-iso-prostaglandin-F2α in the subarachnoid haematoma increased significantly at 3 h after SAH in animals with normal neutrophil counts indicating oxidative stress, which was not the case in neutropenic SAH animals. These results suggest that neutrophils are important mediators of cortical hypoperfusion and oxidative stress early after SAH. Targeting neutrophil function and neutrophil-induced oxidative stress could be a promising new approach to mitigate cerebral hypoperfusion early after SAH.
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Petridis AK, Kamp MA, Cornelius JF, Beez T, Beseoglu K, Turowski B, Steiger HJ. Aneurysmal Subarachnoid Hemorrhage. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:226-236. [PMID: 28434443 DOI: 10.3238/arztebl.2017.0226] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 08/29/2016] [Accepted: 11/28/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is associated with a mortality of more than 30%. Only about 30% of patients with SAB recover sufficiently to return to independent living. METHODS This article is based on a selective review of pertinent literature retrieved by a PubMed search. RESULTS Acute, severe headache, typically described as the worst headache of the patient's life, and meningismus are the characteristic manifestations of SAH. Computed tomog raphy (CT) reveals blood in the basal cisterns in the first 12 hours after SAH with approximately 95% sensitivity and specificity. If no blood is seen on CT, a lumbar puncture must be performed to confirm or rule out the diagnosis of SAH. All patients need intensive care so that rebleeding can be avoided and the sequelae of the initial bleed can be minimized. The immediate transfer of patients with acute SAH to a specialized center is crucially important for their outcome. In such centers, cerebral aneurysms can be excluded from the circulation either with an interventional endovascular procedure (coiling) or by microneurosurgery (clipping). CONCLUSION SAH is a life-threatening condition that requires immediate diagnosis, transfer to a neurovascular center, and treatment without delay.
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Affiliation(s)
- Athanasios K Petridis
- Department of Neurosurgery, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital; Department of Diagnostic and Interventional Radiology, Düsseldorf University Hospital
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Wang AYC, Hsieh PC, Chen CC, Chin SC, Wu YM, Chen CT, Chang CH, Wu TWE. Effect of Intracranial Pressure Control on Improvement of Cerebral Perfusion After Acute Subarachnoid Hemorrhage: A Comparative Angiography Study Based on Temporal Changes of Intracranial Pressure and Systemic Pressure. World Neurosurg 2018; 120:e290-e296. [PMID: 30142432 DOI: 10.1016/j.wneu.2018.08.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/07/2018] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Increased intracranial pressure (ICP) is a well-known complication after aneurysmal subarachnoid hemorrhage (aSAH). This study focused on the different temporal changes in ICP, mean arterial pressure, and cerebral perfusion pressure at the early stage of aSAH, throughout aneurysm embolization, and their effects on improvement in angiographic perfusion patterns. METHODS Twenty-seven patients with aSAH were evaluated who underwent coiling and cerebrospinal fluid (CSF) drainage. Diagnostic angiography was performed to confirm the presence and location of the vascular lesion. The transit time of the capillary filling phase was defined as a surrogate of cerebral perfusion. Capillary filling transit times were compared before and after CSF drainage. Univariate and multivariate analyses were performed to identify associations between different physical parameters and capillary filling transit times. RESULTS By univariate analysis, average capillary transit time before CSF drainage had a significant correlation with initial ICP (P = 0.0004; R2 = 0.398) but not systemic pressure (mean arterial pressure or cerebral perfusion pressure). Improvement in capillary filling pattern (i.e., a decrease in angiographic capillary transit time after CSF drainage) was seen in patients with high initial ICP and correlated with ICP difference after ventricular drainage (P = 0.0001 and P < 0.0001, respectively). Using multivariate regression analysis, improved control in postprocedural ICP levels significantly correlated with angiographic evidence of improved cerebral perfusion (P = 0.0243). CONCLUSIONS Decreasing ICP by CSF drainage strongly correlated with improved cerebral microcirculation after aSAH. Further development of ICP control protocols that can provide better ICP management of patients with aSAH is warranted.
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Affiliation(s)
- Alvin Yi-Chou Wang
- Department of Neurosurgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China.
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Shy-Chyi Chin
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Yi-Ming Wu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Chun-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Chien-Hung Chang
- Department of Neurology, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Tai-Wei Erich Wu
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
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Hsieh PC, Wu YM, Wang AYC, Chen CC, Chang CH, Chin SC, Wu TWE, Wu CT, Lee ST. The venous delay phenomenon in computed tomography angiography: a novel imaging outcome predictor for poor cerebral perfusion after severe aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 129:876-882. [PMID: 29171807 DOI: 10.3171/2017.5.jns17794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Diverse treatment results are observed in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). Significant initial perfusion compromise is thought to predict a worse treatment outcome, but this has scant support in the literature. In this cohort study, the authors correlate the treatment outcomes with a novel poor-outcome imaging predictor representing impaired cerebral perfusion on initial CT angiography (CTA). METHODS The authors reviewed the treatment results of 148 patients with poor-grade aSAH treated at a single tertiary referral center between 2007 and 2016. Patients with the "venous delay" phenomenon on initial CTA were identified. The outcome assessments used the modified Rankin Scale (mRS) at the 3rd month after aSAH. Factors that may have had an impact on outcome were retrospectively analyzed. RESULTS Compared with previously identified outcome predictors, the venous delay phenomenon on initial CTA was found to have the strongest correlation with posttreatment outcomes on both univariable (p < 0.0001) and multivariable analysis (OR 4.480, 95% CI 1.565-12.826; p = 0.0052). Older age and a higher Hunt and Hess grade at presentation were other factors that were associated with poor outcome, defined as an mRS score of 3 to 6. CONCLUSIONS The venous delay phenomenon on initial CTA can serve as an imaging predictor for worse functional outcome and may aid in decision making when treating patients with poor-grade aSAH.
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Affiliation(s)
| | | | | | | | - Chien-Hung Chang
- 3Neurology, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Kweishan, Taoyuan, Taiwan
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van Lieshout JH, Dibué-Adjei M, Cornelius JF, Slotty PJ, Schneider T, Restin T, Boogaarts HD, Steiger HJ, Petridis AK, Kamp MA. An introduction to the pathophysiology of aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2017; 41:917-930. [PMID: 28215029 DOI: 10.1007/s10143-017-0827-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 02/06/2023]
Abstract
Pathophysiological processes following subarachnoid hemorrhage (SAH) present survivors of the initial bleeding with a high risk of morbidity and mortality during the course of the disease. As angiographic vasospasm is strongly associated with delayed cerebral ischemia (DCI) and clinical outcome, clinical trials in the last few decades focused on prevention of these angiographic spasms. Despite all efforts, no new pharmacological agents have shown to improve patient outcome. As such, it has become clear that our understanding of the pathophysiology of SAH is incomplete and we need to reevaluate our concepts on the complex pathophysiological process following SAH. Angiographic vasospasm is probably important. However, a unifying theory for the pathophysiological changes following SAH has yet not been described. Some of these changes may be causally connected or present themselves as an epiphenomenon of an associated process. A causal connection between DCI and early brain injury (EBI) would mean that future therapies should address EBI more specifically. If the mechanisms following SAH display no causal pathophysiological connection but are rather evoked by the subarachnoid blood and its degradation production, multiple treatment strategies addressing the different pathophysiological mechanisms are required. The discrepancy between experimental and clinical SAH could be one reason for unsuccessful translational results.
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Affiliation(s)
- Jasper H van Lieshout
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Maxine Dibué-Adjei
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Toni Schneider
- Institute for Neurophysiology, Medical Faculty, University of Cologne, Robert-Koch-Str. 39, 50931, Köln, Germany
| | - Tanja Restin
- Zurich Centre for Integrative Human Physiology, Institute of Physiology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Institute of Anesthesiology, Medical Faculty, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Medical Faculty, Radboud University Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Athanasios K Petridis
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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van Lieshout JH, Bruland I, Fischer I, Cornelius JF, Kamp MA, Turowski B, Tortora A, Steiger HJ, Petridis AK. Increased mortality of patients with aneurysmatic subarachnoid hemorrhage caused by prolonged transport time to a high-volume neurosurgical unit. Am J Emerg Med 2017; 35:45-50. [DOI: 10.1016/j.ajem.2016.09.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/07/2016] [Accepted: 09/29/2016] [Indexed: 01/03/2023] Open
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Prognostic Assessment of Aneurysmal Subarachnoid Patients with WFNS Grade V by CT Perfusion on Arrival. World Neurosurg 2016; 92:1-6. [PMID: 27155385 DOI: 10.1016/j.wneu.2016.04.097] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/25/2016] [Accepted: 04/25/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND The prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) depends on their condition on arrival at the hospital. However, a small number of patients recover from an initially poor condition. We investigated the correlation between quantitative measures of computed tomography (CT) perfusion (CTP) on arrival and the outcomes of patients with World Federation of Neurosurgical Society (WFNS) grade V aSAH. METHODS We performed plain CT, CTP, and CT angiography (CTA) in all patients with aSAH on arrival. Aneurysms were surgically obliterated in patients with stable vital signs and the presence of a brain stem response. We measured the average mean transit time (aMTT) and compared it with the modified Rankin Scale (mRS) score at 1 month. Regions of interest were identified as 24 areas in the bilateral anterior, middle, and posterior cerebral artery territories and 2 areas in the basal ganglia. RESULTS A total of 57 patients were treated between 2007 and 2014. None of the 21 patients with aMTT >6.385 seconds achieved a favorable outcome, whereas 8 of the 36 patients with aMTT <6.385 seconds did achieve a favorable outcome (P = 0.015). Furthermore, comparing the number of areas showing a mean transit time (MTT) >7.0 seconds among the aforementioned 8 areas and mRS, favorable outcomes were not seen in 24 patients with more than 2 such areas (P = 0.009). CONCLUSION We cannot expect a favorable outcome for patients with WFNS grade V aSAH with aMTT >6.385 seconds or more than 2 of 8 areas with MTT >7.0 seconds.
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Jabbarli R, Reinhard M, Shah M, Roelz R, Niesen WD, Kaier K, Taschner C, Weyerbrock A, Van Velthoven V. Early Vasospasm after Aneurysmal Subarachnoid Hemorrhage Predicts the Occurrence and Severity of Symptomatic Vasospasm and Delayed Cerebral Ischemia. Cerebrovasc Dis 2016; 41:265-72. [DOI: 10.1159/000443744] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 12/30/2015] [Indexed: 11/19/2022] Open
Abstract
Background: Cerebral vasospasm usually develops several days after subarachnoid hemorrhage (SAH) and is generally acknowledged as a strong outcome predictor. In contrast, much less is known about the nature and eventual consequences of early angiographic vasospasm (EAVS) seen on admission digital subtraction angiography (DSA). Therefore, we aimed at identifying the risk factors and clinical impact of EAVS after SAH. Methods: Five hundred and thirty-one SAH patients with admission DSA performed within 72 h after the bleeding event were selected from a comprehensive database containing all consecutive SAH patients treated at our institution between January 2005 and December 2012. Predictors of EAVS, as well as associations between EAVS and delayed vasospasm-related complications, and unfavorable outcome (defined as modified Rankin scale >3) were evaluated in univariate and multivariate analyses. Results: EAVS was seen on 60 DSAs (11.3%) and was independently correlated with delayed symptomatic vasospasm requiring intra-arterial spasmolysis (OR 5.24, p < 0.0001), angioplasty (OR 2.56, p = 0.015) and repetitive endovascular treatment (OR 4.71, p < 0.0001). EAVS also increased the risk for multiple versus single territorial infarction on the follow-up CT scan(s) (OR 2.04, p = 0.047) and independently predicted unfavorable outcome (OR 2.93, p = 0.008). The presence of radiographic signs suspicious for fibromuscular dysplasia were independently associated with the occurrence of EAVS (OR 2.98, p = 0.026) and the need for repetitive endovascular vasospasm treatment (OR 3.95, p = 0.019). Conclusions: In view of the strong correlation with delayed symptomatic vasospasm and its ischemic complications, EAVS can be considered an alerting signal for severe symptomatic vasospasm. Therefore, more attention should be paid to the presence of EAVS on admission DSA.
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Effect of APOE Gene Polymorphism on Early Cerebral Perfusion After Aneurysmal Subarachnoid Hemorrhage. Transl Stroke Res 2015; 6:446-50. [DOI: 10.1007/s12975-015-0426-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 10/23/2022]
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15
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Caspers J, Rubbert C, Turowski B, Martens D, Reichelt DC, May R, Aissa J, Hänggi D, Etminan N, Mathys C. Timing of Mean Transit Time Maximization is Associated with Neurological Outcome After Subarachnoid Hemorrhage. Clin Neuroradiol 2015; 27:15-22. [PMID: 25939528 DOI: 10.1007/s00062-015-0399-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/15/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE Computed tomography perfusion (CTP) has gained significant relevance for the radiological screening of patients at risk of developing delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Particularly, the impact of MTTPEAK, i.e., the maximal mean transit time value in a series of CTP measurements, for the prediction of long-term outcome has recently been demonstrated by our group. Complementing this recent work, the present study investigated how the timing of MTTPEAK affected the long-term outcome after aneurysmal subarachnoid hemorrhage. METHODS CTP examinations from 103 patients with clinical deterioration attributed to DCI after aSAH were retrospectively analyzed for time interval between SAH ictus and onset of MTTPEAK in association with modified Rankin Scale (mRS) 23.1 months after SAH. RESULTS Patients with unfavorable outcome (mRS > = 2) suffered significant earlier MTTPEAK onsets than patients with favorable outcome (mRS = 0 and 1). MTTPEAK within the first week was associated with significantly higher mRS scores compared to later MTTPEAK. Timing of MTTPEAK together with the value of MTTPEAK and initial World Federation of Neurosurgical Societies (WFNS) grade was a significant predictor for an unfavorable outcome (mRS > = 2). CONCLUSIONS The current findings suggest a presumably higher vulnerability of the brain to early microcirculatory impairments after aSAH and highlight that timing of MTT elevations could be considered for the identification of patients at increased risk for poor neurological outcome due to DCI.
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Affiliation(s)
- J Caspers
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, 52425, Jülich, Germany
| | - C Rubbert
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany.
| | - B Turowski
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D Martens
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D C Reichelt
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - R May
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - J Aissa
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - D Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University, 40225, Dusseldorf, Germany
| | - N Etminan
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University, 40225, Dusseldorf, Germany
| | - C Mathys
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225, Dusseldorf, Germany
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Beseoglu K, Etminan N, Hänggi D. The value of perfusion computed tomography (PCT) imaging after aneurysmal subarachnoid hemorrhage: a review of the current data. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:35-8. [PMID: 25366596 DOI: 10.1007/978-3-319-04981-6_6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND PURPOSE The estimation of the extent of early brain injury (EBI) and sensitive detection of delayed cerebral ischemia (DCI) remains a major challenge in the context of aneurysmal subarachnoid hemorrhage (aSAH). Cerebral perfusion computed tomography (PCT) imaging is increasingly used as an additional diagnostic tool to monitor early brain injury as well as delayed cerebral ischemia after aSAH. Here, we review the current literature as well as the resulting implications and illustrate our institutional experience with PCT imaging in this context. METHODS The current literature on PCT imaging for SAH was identified based on a search of the PubMed database. Patient cohorts were dichotomized according to the time of PCT after ictus into early PCT (<72 h after ictus) and subsequent PCT (>72 h after ictus). The specific aspects and findings of PCT at different times are compared and discussed. RESULTS Sixteen relevant publications were identified, nine of which focused on early PCT and seven on subsequent PCT diagnostics after aSAH. Early PCT provided relevant details on the extent of EBI and identified patients at risk for developing DCI, whereas subsequent PCT imaging facilitated the monitoring and detection of DCI. CONCLUSIONS The present review demonstrates that PCT imaging is able to detect EBI as well as DCI in patients experiencing aSAH. As a consequence, this technique should be routinely implemented in monitoring strategies for this patient population.
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Affiliation(s)
- Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, Düsseldorf, 40225, Germany,
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Sorimachi T, Osada T, Aoki R, Nishiyama J, Hirayama A, Srivatanakul K, Matsumae M. Density of the cerebral cortex in computed tomography angiography source images and clinical outcomes in Grade V subarachnoid hemorrhage. Neurol Res 2015; 37:484-90. [DOI: 10.1179/1743132815y.0000000001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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18
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Etminan N, Beseoglu K, Heiroth HJ, Turowski B, Steiger HJ, Hänggi D. Early Perfusion Computerized Tomography Imaging as a Radiographic Surrogate for Delayed Cerebral Ischemia and Functional Outcome After Subarachnoid Hemorrhage. Stroke 2013; 44:1260-6. [DOI: 10.1161/strokeaha.111.675975] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Nima Etminan
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Kerim Beseoglu
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hi-Jae Heiroth
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Bernd Turowski
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hans Jakob Steiger
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Daniel Hänggi
- From the Department of Neurosurgery (N.E., K.B. H.H, H.-J.S., D.H.) and Institute for Diagnostic and Interventional Radiology (B.T.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
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