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Tjerkstra MA, Post R, Germans MR, Vergouwen MDI, Jellema K, Koot RW, Kruyt ND, Wolfs JFC, De Beer FC, Kieft HH, Nanda D, Van Der Pol B, Roks G, De Beer F, Reichman LJA, Brouwers PJAM, Kwa VIH, Van Der Ree TC, Bienfait HP, Boogaarts HD, Klijn CJ, Visser V, van den Berg R, Coert BA, Horn J, Majoie CBLM, Rinkel GJE, Roos YBWEM, Vandertop WP, Verbaan D. Ultra-Early and Short-Term Tranexamic Acid Treatment in Patients With Good- and Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Neurology 2024; 102:e209169. [PMID: 38788175 DOI: 10.1212/wnl.0000000000209169] [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] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The results of the ULTRA trial showed that ultra-early and short-term treatment with tranexamic acid (TXA) does not improve clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH). Possibly, the lack of a beneficial effect in all patients with aSAH is masked by antagonistic effects of TXA in certain subgroups. In this post hoc subgroup analysis, we investigated the effect of TXA on clinical outcome in patients with good-grade and poor-grade aSAH. METHODS The ULTRA trial was a multicenter, prospective, randomized, controlled, open-label trial with blinded outcome assessment. Participants received ultra-early and short-term TXA in addition to usual care or usual care only. This post hoc subgroup analysis included only ULTRA participants with confirmed aSAH and available World Federation of Neurosurgical Societies (WFNS) grade on admission. Patients were categorized into those with good-grade (WFNS 1-3) and poor-grade (WFNS 4-5) aSAH. The primary outcome was clinical outcome assessed by the modified Rankin scale (mRS). Odds ratios (ORs) and adjusted ORs (aORs) with 95% CIs were calculated using ordinal regression analyses. Analyses were performed using the as-treated principle. In all patients with aSAH, no significant effect modification of TXA on clinical outcome was observed for admission WFNS grade (p = 0.10). RESULTS Of the 812 ULTRA participants, 473 patients had (58%; N = 232 TXA, N = 241 usual care) good-grade and 339 (42%; N = 162 TXA, N = 176 usual care) patients had poor-grade aSAH. In patients with good-grade aSAH, the TXA group had worse clinical outcomes (OR: 0.67, 95% CI 0.48-0.94, aOR 0.68, 95% CI 0.48-0.94) compared with the usual care group. In patients with poor-grade aSAH, clinical outcomes were comparable between treatment groups (OR: 1.04, 95% CI 0.70-1.55, aOR 1.05, 95% CI 0.70-1.56). DISCUSSION This post hoc subgroup analysis provides another important argument against the use of TXA treatment in patients with aSAH, by showing worse clinical outcomes in patients with good-grade aSAH treated with TXA and no clinical benefit of TXA in patients with poor-grade aSAH, compared with patients treated with usual care. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov (NCT02684812; submission date February 18, 2016, first patient enrollment on July 24, 2013). CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tranexamic acid, given for <24 hours within the first 24 hours, does not improve the 6-month outcome in good-grade or poor initial-grade aneurysmal SAH.
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Affiliation(s)
- Maud A Tjerkstra
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - René Post
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Menno R Germans
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Mervyn D I Vergouwen
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Korne Jellema
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Radboud W Koot
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Nyika D Kruyt
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Jasper F C Wolfs
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Frits C De Beer
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Hans H Kieft
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Dharmin Nanda
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Bram Van Der Pol
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Gerwin Roks
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Frank De Beer
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Loes J A Reichman
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Paul J A M Brouwers
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Vincent I H Kwa
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Taco C Van Der Ree
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Henri P Bienfait
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Hieronymus D Boogaarts
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Catharina J Klijn
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Victoria Visser
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - René van den Berg
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Bert A Coert
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Janneke Horn
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Charles B L M Majoie
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Gabriël J E Rinkel
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Yvo B W E M Roos
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - W Peter Vandertop
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Dagmar Verbaan
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
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Terrett LA, McIntyre L, O'Kelly C, Ramsay T, Turgeon AF, English SW. Blood Pressure Management in Early Aneurysmal Subarachnoid Hemorrhage: A National Cross-Sectional Survey of Canadian Intensivists and Cerebrovascular Neurosurgeons. Neurocrit Care 2024:10.1007/s12028-024-02011-4. [PMID: 38862709 DOI: 10.1007/s12028-024-02011-4] [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: 01/29/2024] [Accepted: 05/09/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND In aneurysmal subarachnoid hemorrhage (aSAH), rebleeding of the culprit aneurysm is associated with significant morbidity and mortality. Blood pressure reduction to specific target levels, with the goal of preventing rebleeding, has been a mainstay of care prior to definitively securing the aneurysm. Clinical practice guidelines have recently changed and no longer recommend specific blood pressure targets. This survey aims to identify the reported practice patterns and beliefs regarding blood pressure management during the early phase of aSAH. METHODS We conducted a self-administered, Web-based survey of critical care physicians and cerebrovascular neurosurgeons practicing in Canada. The questionnaire contained 21 items, including 3 case-based scenarios to elicit blood pressure target selection, both before and after aneurysm securing. RESULTS In the presecured period, systolic blood pressures of 160 mm Hg (50% [144 of 287]) and 140 mm Hg (42% [120 of 287]) were the most frequently selected upper-limit targets. In the postsecured period, a systolic blood pressure of 180 mm Hg (32% [93 of 287]) was the most frequently selected upper-limit target, but there was a wide distribution of targets selected across all three cases ranging from 100 to > 200 mm Hg. A mean arterial pressure of 65 mm Hg was the most common lower-limit target in both the presecured and postsecured periods. There was little change in blood pressure targets with increasing clinical severity. Predictors of higher or lower blood pressure target selection and barriers to implementation of the desired target were identified. CONCLUSIONS During the presecured period, nearly half of the reported upper-limit blood pressure targets are lower than previous guideline recommendations. These targets remain consistent despite increasing clinical severity and could potentially exacerbate cerebral ischemia and negatively impact clinical outcomes. In the postsecured period, there is wide variation in the reported blood pressure targets. A clinical trial is urgently needed to guide decision-making.
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Affiliation(s)
- Luke A Terrett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.
- Department of Adult Critical Care, Saskatchewan Health Authority, 103 Hospital Drive, Saskatoon, SK, S7N0W8, Canada.
| | - Lauralyn McIntyre
- Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Cian O'Kelly
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Tim Ramsay
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Unit, Centre Hospitalier Universitaire de Québec - Université Laval Research Center, Quebec City, QC, Canada
| | - Shane W English
- Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
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Park S. Emergent Management of Spontaneous Subarachnoid Hemorrhage. Continuum (Minneap Minn) 2024; 30:662-681. [PMID: 38830067 DOI: 10.1212/con.0000000000001428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Spontaneous subarachnoid hemorrhage (SAH) carries high morbidity and mortality rates, and the emergent management of this disease can make a large impact on patient outcome. The purpose of this article is to provide a pragmatic overview of the emergent management of SAH. LATEST DEVELOPMENTS Recent trials have influenced practice around the use of antifibrinolytics, the timing of aneurysm securement, the recognition of cerebral edema and focus on avoiding a lower limit of perfusion, and the detection and prevention of delayed cerebral ischemia. Much of the acute management of SAH can be protocolized, as demonstrated by two updated guidelines published by the American Heart Association/American Stroke Association and the Neurocritical Care Society in 2023. However, the gaps in evidence lead to clinical equipoise in some aspects of critical care management. ESSENTIAL POINTS In acute management, there is an urgency to differentiate the etiology of SAH and take key emergent actions including blood pressure management and coagulopathy reversal. The critical care management of SAH is similar to that of other acute brain injuries, with the addition of detecting and treating delayed cerebral ischemia. Strategies for the detection and treatment of delayed cerebral ischemia are limited by disordered consciousness and may be augmented by monitoring and imaging technology.
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Anna A, Marita D, Lars E, Lovisa T, Lotti O. Patients with aneurysmal subarachnoid haemorrhage treated in Swedish intensive care: A registry study. Acta Anaesthesiol Scand 2024. [PMID: 38812348 DOI: 10.1111/aas.14453] [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: 12/11/2023] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening disease with high mortality and morbidity. Patients with aSAH in Sweden are cared for at one of six neuro intensive care units (NICU) or at a general intensive care unit (ICU).This study aimed to describe the incidence, length of stay, time in ventilator and mortality for these patients. METHODS This is a retrospective, descriptive study of patients with aSAH, registered in the Swedish Intensive care Registry between 2017 and 2019. The cohort was divided in sub-cohorts (NICU and general ICU) and regions. Mortality was analysed with logistic regression. RESULTS A total of 1520 patients with aSAH from five regions were included in the study. Mean age of the patients were 60.6 years and 58% were female. Mortality within 180 days of admission was 30% (n = 456) of which 17% (n = 258) died during intensive care. A majority of the patients were treated at one hospital and in one ICU (70%, n = 1062). More than half of the patients (59%, n = 897) had their first intensive care admission at a hospital with a NICU. Patients in the North region had the lowest median GCS (10) and the highest SAPS3 score (60) when admitted to NICU. Treatment with invasive mechanical ventilation differed significantly between regions; 91% (n = 80) in the region with highest proportion versus 56% (n = 94) in the region with the lowest proportion, as did mortality; 16% (n = 44) versus 8% (n = 23). No differences between regions were found regarding age, sex and length of stay. CONCLUSIONS Patients with aSAH treated in a NICU or in an ICU in Sweden differs in characteristics. The study further showed some differences between regions which might be reduced if there were national consensus and treatment guidelines implemented.
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Affiliation(s)
- Arnlind Anna
- Department of Neurosurgery in Linköping, University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Danielsson Marita
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- The Swedish National Patient Insurance Company (Löf), Stockholm, Sweden
| | - Engerström Lars
- Department of Anaesthesiology and Intensive Care, Vrinnevi Hospital, Norrköping, Sweden
- Department of Thoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Tobieson Lovisa
- Department of Neurosurgery in Linköping, University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Orwelius Lotti
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Anaesthesiology and Intensive Care, University Hospital, Linköping, Sweden
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Lenkeit A, Oppong MD, Dinger TF, Gümüs M, Rauschenbach L, Chihi M, Ahmadipour Y, Uerschels AK, Dammann P, Deuschl C, Wrede KH, Sure U, Jabbarli R. Risk factors for poor outcome after aneurysmal subarachnoid hemorrhage in patients with initial favorable neurological status. Acta Neurochir (Wien) 2024; 166:93. [PMID: 38376665 PMCID: PMC10879324 DOI: 10.1007/s00701-024-05968-5] [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: 08/02/2023] [Accepted: 11/20/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) remains a devastating diagnosis. A poor outcome is known to be highly dependent on the initial neurological status. Our goal was to identify other parameters that favor the risk of complications and poor outcome in patients with aSAH and initially favorable neurologic status. METHODS Consecutive aSAH cases treated at our hospital between 01/2003 and 06/2016 with the initial World Federation of Neurosurgical Societies grades I-III were included. Data on demographic characteristics, previous medical history, initial aSAH severity, and functional outcome after aSAH were collected. The study endpoints were the occurrence of cerebral infarcts, in-hospital mortality, and unfavorable outcome at 6 months after aSAH (modified Rankin scale > 3). RESULTS In the final cohort (n= 582), the rate of cerebral infarction, in-hospital mortality, and unfavorable outcome was 35.1%, 8.1%, and 17.6% respectively. The risk of cerebral infarction was independently related to the presence of acute hydrocephalus (adjusted odds ratio [aOR]=2.33, p<0.0001), aneurysm clipping (aOR=1.78, p=0.003), and use of calcium channel blockers concomitant to nimodipine (aOR=2.63, p=0.002). Patients' age (>55 years, aOR=4.24, p<0.0001), acute hydrocephalus (aOR=2.43, p=0.036), and clipping (aOR=2.86, p=0.001) predicted in-hospital mortality. Baseline characteristics associated with unfavorable outcome at 6 months were age (aOR=2.77, p=<0.0001), Fisher grades III-IV (aOR=2.81, p=0.016), acute hydrocephalus (aOR=2.22, p=0.012), clipping (aOR=3.98, p<0.0001), admission C-reactive protein>1mg/dL (aOR=1.76, p=0.035), and treatment intervals (aOR=0.64 per-5-year-intervals, p=0.006). CONCLUSIONS Although cerebral infarction is a common complication in aSAH individuals with favorable initial clinical condition, >80% of these patients show favorable long-term outcome. The knowledge of outcome-relevant baseline characteristics might help to reduce the burden of further complications and poor outcome in aSAH patients who tolerated the initial bleeding event well.
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Affiliation(s)
- Annika Lenkeit
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Meltem Gümüs
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Anne-Kathrin Uerschels
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Cornelius Deuschl
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
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Kang J, Tian S, Zhang L, Yang G. Ferroptosis in early brain injury after subarachnoid hemorrhage: review of literature. Chin Neurosurg J 2024; 10:6. [PMID: 38347652 PMCID: PMC10863120 DOI: 10.1186/s41016-024-00357-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/28/2024] [Indexed: 02/15/2024] Open
Abstract
Spontaneous subarachnoid hemorrhage (SAH), mainly caused by ruptured intracranial aneurysms, is a serious acute cerebrovascular disease. Early brain injury (EBI) is all brain injury occurring within 72 h after SAH, mainly including increased intracranial pressure, decreased cerebral blood flow, disruption of the blood-brain barrier, brain edema, oxidative stress, and neuroinflammation. It activates cell death pathways, leading to neuronal and glial cell death, and is significantly associated with poor prognosis. Ferroptosis is characterized by iron-dependent accumulation of lipid peroxides and is involved in the process of neuron and glial cell death in early brain injury. This paper reviews the research progress of ferroptosis in early brain injury after subarachnoid hemorrhage and provides new ideas for future research.
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Affiliation(s)
- Junlin Kang
- The First Hospital of Lanzhou University, Lanzhou City, Gansu Province, China
| | - Shilai Tian
- The First Hospital of Lanzhou University, Lanzhou City, Gansu Province, China
| | - Lei Zhang
- Gansu Provincial Hospital, Lanzhou City, Gansu Province, China
| | - Gang Yang
- The First Hospital of Lanzhou University, Lanzhou City, Gansu Province, China.
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Mei Q, Shen H, Liu J. A nomogram for the prediction of short-term mortality in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation: a post-hoc analysis. Front Neurol 2024; 14:1280047. [PMID: 38259653 PMCID: PMC10800534 DOI: 10.3389/fneur.2023.1280047] [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: 09/04/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating stroke subtype with high morbidity and mortality. Although several studies have developed a prediction model in aSAH to predict individual outcomes, few have addressed short-term mortality in patients requiring mechanical ventilation. The study aimed to construct a user-friendly nomogram to provide a simple, precise, and personalized prediction of 30-day mortality in patients with aSAH requiring mechanical ventilation. Methods We conducted a post-hoc analysis based on a retrospective study in a French university hospital intensive care unit (ICU). All patients with aSAH requiring mechanical ventilation from January 2010 to December 2015 were included. Demographic and clinical variables were collected to develop a nomogram for predicting 30-day mortality. The least absolute shrinkage and selection operator (LASSO) regression method was performed to identify predictors, and multivariate logistic regression was used to establish a nomogram. The discriminative ability, calibration, and clinical practicability of the nomogram to predict short-term mortality were tested using the area under the curve (AUC), calibration plot, and decision curve analysis (DCA). Results Admission GCS, SAPS II, rebleeding, early brain injury (EBI), and external ventricular drain (EVD) were significantly associated with 30-day mortality in patients with aSAH requiring mechanical ventilation. Model A incorporated four clinical factors available in the early stages of the aSAH: GCS, SAPS II, rebleeding, and EBI. Then, the prediction model B with the five predictors was developed and presented in a nomogram. The predictive nomogram yielded an AUC of 0.795 [95% CI, 0.731-0.858], and in the internal validation with bootstrapping, the AUC was 0.780. The predictive model was well-calibrated, and decision curve analysis further confirmed the clinical usefulness of the nomogram. Conclusion We have developed two models and constructed a nomogram that included five clinical characteristics to predict 30-day mortality in patients with aSAH requiring mechanical ventilation, which may aid clinical decision-making.
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Affiliation(s)
- Qing Mei
- Department of Neurology, Beijing Pinggu Hospital, Beijing, China
| | - Hui Shen
- Department of Interventional Neuroradiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Functional Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Centre of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou, China
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Pendse RS, Castro LF, Din S, Barrios Y, Baronia BC. An Excellent Functional Recovery Following Grade IV Subarachnoid Hemorrhage From a Cerebral Aneurysm Rebleed With Ultra-Early Surgical Intervention: A Case Report. Cureus 2023; 15:e47197. [PMID: 38022085 PMCID: PMC10652662 DOI: 10.7759/cureus.47197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Aneurysms are focal abnormal dilations of the arterial wall occurring frequently at branching points along the arteries of the base of the brain. Aneurysmal rupture is one of the possible aneurysm complications and can cause aneurysmal subarachnoid hemorrhages (aSAH). Treatment of aSAH consists of pharmacologic, surgical, or endovascular approaches. The ultra-early intervention of ruptured aSAH occurs within the first 24 hours after ruptured aSAH. This case is about a 49-year-old obese male with multiple comorbidities who suffered from a grade IV subarachnoid hemorrhage and underwent an ultra-early surgical clipping approximately four hours after admission to the emergency center. The patient had excellent functional recovery at a six-month follow-up. Ultra-early surgical intervention for high-grade aSAH with rebleeding could improve outcomes.
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Affiliation(s)
- Rohan S Pendse
- Department of Neurological Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Luis F Castro
- Department of Neurology, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Sarosh Din
- School of Osteopathic Medicine, William Carey College of Osteopathic Medicine, Hattiesburg, USA
| | - Yesenia Barrios
- Department of Emergency Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Benedicto C Baronia
- Department of Neurological Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
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Chang CWJ, Provencio JJ, Pascual J, Heavner MS, Olson D, Livesay SL, Kaplan LJ. State-of-the-Art Evaluation of Acute Adult Disorders of Consciousness for the General Intensivist. Crit Care Med 2023; 51:948-963. [PMID: 37070819 DOI: 10.1097/ccm.0000000000005893] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVES To provide a concise review of knowledge and practice pertaining to the diagnosis and initial management of unanticipated adult patient disorders of consciousness (DoC) by the general intensivist. DATA SOURCES Detailed search strategy using PubMed and OVID Medline for English language articles describing adult patient acute DoC diagnostic evaluation and initial management strategies including indications for transfer. STUDY SELECTION Descriptive and interventional studies that address acute adult DoC, their evaluation and initial management, indications for transfer, as well as outcome prognostication. DATA EXTRACTION Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for adult critical care practice. DATA SYNTHESIS Acute adult DoC may be categorized by etiology including structural, functional, infectious, inflammatory, and pharmacologic, the understanding of which drives diagnostic investigation, monitoring, acute therapy, and subsequent specialist care decisions including team-based local care as well as intra- and inter-facility transfer. CONCLUSIONS Acute adult DoC may be initially comprehensively addressed by the general intensivist using an etiology-driven and team-based approach. Certain clinical conditions, procedural expertise needs, or resource limitations inform transfer decision-making within a complex care facility or to one with greater complexity. Emerging collaborative science helps improve our current knowledge of acute DoC to better align therapies with underpinning etiologies.
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Affiliation(s)
| | | | - Jose Pascual
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mojdeh S Heavner
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - DaiWai Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern, Dallas, TX
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Duration between aneurysm rupture and treatment and its association with outcome in aneurysmal subarachnoid haemorrhage. Sci Rep 2023; 13:1527. [PMID: 36707604 PMCID: PMC9883503 DOI: 10.1038/s41598-022-27177-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/27/2022] [Indexed: 01/29/2023] Open
Abstract
Timely treatment of aneurysmal subarachnoid haemorrhage (aSAH) is key to prevent further rupture and poor outcome. We evaluated complications and outcome adjusting for time from haemorrhage to treatment. Retrospective analysis of aSAH patients admitted between 2006 and 2020. Data was collected using standardized case report forms. We compared risk factors using multivariable logistic regression. We included 853 patients, 698 (81.8%) were treated within 24 h. Patients with higher Hunt and Hess grades were admitted and treated significantly faster than those with lower grades (overall p-value < 0.001). Fifteen patients (1.8%) rebled before intervention. In the multivariable logistic analysis adjusting for timing, Barrow Neurological Institute score and intracerebral haemorrhage were significantly associated with rebleeding (overall p-value 0.006; OR 3.12, 95%CI 1.09-8.92, p = 0.03, respectively) but timing was not. Treatment > 24 h was associated with higher mortality and cerebral infarction in only the subgroup of lower grades aSAH (OR 3.13, 1.02-9.58 95%CI, p-value = 0.05; OR 7.69, 2.44-25.00, p-value < 0.001, respectively). Therefore treatment > 24 h after rupture is associated with higher mortality and cerebral infarction rates in lower grades aSAH. Delay in treatment primarily affects lower grade aSAH patients. Patients with lower grade aSAH ought to be treated with the same urgency as higher-grade aSAH.
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Ghaith HS, Gabra MD, Ebada MA, Dada OE, Al-Shami H, Bahbah EI, Swed S, Ghaith AK, Kanmounye US, Esene IN, Negida A. Tranexamic acid for patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of 2991 patients. Int J Neurosci 2022:1-14. [PMID: 36463556 DOI: 10.1080/00207454.2022.2148957] [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: 04/24/2022] [Revised: 06/24/2022] [Accepted: 06/30/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE We aimed to synthesize evidence from published clinical trials on the efficacy and safety of tranexamic acid (TXA) administration in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS We followed the standard methods of the Cochrane Handbook of Systematic Reviews for interventions and the PRISMA statement guidelines 2020 when conducting and reporting this study. A computer literature search of PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted from inception until 1 January 2022. We selected observational studies and clinical trials comparing TXA versus no TXA in aSAH patients. Data of all outcomes were pooled as the risk ratio (RR) with the corresponding 95% confidence intervals in the meta-analysis models. RESULTS Thirteen studies with a total of 2991 patients were included in the analysis. TXA could significantly cut the risk of rebleeding (RR 0.56, 95% CI 0.44 to 0.72) and mortality from rebleeding (RR 0.60, 95% CI 0.39 to 0.92, p = 0.02). However, TXA did not significantly improve the overall mortality, neurological outcome, delayed cerebral ischemia, or hydrocephalus (all p > 0.05). In terms of safety, no significant adverse events were reported. No statistical heterogeneity or publication bias was found in all outcomes. CONCLUSION In patients with aSAH, TXA significantly reduces the incidence of rebleeding and mortality from rebleeding. However, current evidence does not support any benefits in overall mortality, neurological outcome, delayed cerebral ischemia, or hydrocephalus.
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Affiliation(s)
- Hazem S Ghaith
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Diaa Gabra
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, South Valley University, Qena, Egypt
| | - Mahmoud Ahmed Ebada
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Resident Physician, Egyptian Fellowship of Neurology, Nasr City Hospital for Health Insurance, Cairo, Egypt
| | | | - Hieder Al-Shami
- Department of Neurosurgery, National Bank Hospital, Nasr City, Egypt
| | - Eshak I Bahbah
- Faculty of Medicine, Al Azhar University, New Damietta, Egypt
| | - Sarya Swed
- Faculty of Medicine, Aleppo University, Syria
| | - Abdul Karim Ghaith
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ignatius N Esene
- Neurosurgery Division, Faculty of Health Sciences, University of Bamenda, Bambili, Cameroon
| | - Ahmed Negida
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, United Kingdom
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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12
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Catapano JS, Lee KE, Rumalla K, Srinivasan VM, Cole TS, Baranoski JF, Winkler EA, Graffeo CS, Alabdly M, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Liver Cirrhosis and Inpatient Mortality in Aneurysmal Subarachnoid Hemorrhage: A Propensity-Adjusted Analysis. World Neurosurg 2022; 167:e948-e952. [PMID: 36055622 DOI: 10.1016/j.wneu.2022.08.113] [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: 06/09/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Liver cirrhosis is associated with an increased risk of aneurysmal subarachnoid hemorrhage (aSAH). However, large studies analyzing the prognosis of cirrhotic patients after aSAH treatment are lacking. This study explores factors associated with inpatient mortality among aSAH patients with cirrhosis. METHODS All patients who underwent open or endovascular treatment for an aSAH at a large quaternary center between January 1, 2003, and July 31, 2019, were retrospectively reviewed. Patients were grouped into cirrhosis versus noncirrhosis groups. Univariate analysis determined variables associated with inpatient mortality. Variables with P < 0.20 were included in a propensity-adjusted multivariable logistic regression analysis to predict inpatient mortality. RESULTS A total of 1419 patients were treated for aSAH; 17 (1.2%) had confirmed cirrhosis. Inpatient mortality was significantly higher among cirrhotic patients than noncirrhotic patients (35.3% vs. 6.8%; P < 0.001). In the univariate analysis for inpatient mortality, the variables cirrhosis, age >65 years, Charlson Comorbidity Index >4, aneurysm size ≥10 mm, Hunt and Hess grade >3, Fisher grade 4, delayed cerebral ischemia (DCI), and posterior circulation aneurysm had P < 0.20 and were included in the multivariable analysis. The propensity-adjusted stepwise multivariable logistic regression analysis showed that cirrhosis (odds ratio [OR]: 12.7, 95% confidence interval [CI]: 3.3-48.7), Hunt and Hess grade >3 (OR: 3.9, 95% CI: 2.3-6.4), Fisher grade 4 (OR: 3.7, 95% CI: 1.3-10.7), and DCI (OR: 2.4, 95% CI: 1.5-3.9) were associated with inpatient mortality (P ≤ 0.01). CONCLUSIONS Cirrhosis was a predictor of inpatient mortality among aSAH patients and was a stronger predictor than DCI or a poor Hunt and Hess grade among patients in this study.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Katriel E Lee
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Muhaiman Alabdly
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
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13
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Krzyżewski RM, Kliś KM, Kwinta BM, Łasocha B, Brzegowy P, Popiela TJ, Gąsowski J. Subarachnoid Hemorrhage from Ruptured Internal Carotid Artery Aneurysm: Association with Arterial Tortuosity. World Neurosurg 2022; 166:e84-e92. [PMID: 35811029 DOI: 10.1016/j.wneu.2022.06.101] [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: 04/05/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Many researchers have found a correlation between tortuous arteries and development of aneurysms in cerebral arteries. We decided to determine whether tortuosity of the internal carotid artery can be related to its aneurysm rupture. METHODS We retrospectively analyzed the internal carotid artery anatomy of 149 patients with internal carotid artery aneurysms. For each patient, we calculated relative length (RL), sum of angle metrics (SOAM), triangular index (TI), product of angle distance (PAD), and inflection count metrics (ICM). RESULTS A total of 33 patients (22.15%) had subarachnoid hemorrhage. These patients had significantly lower SOAM (0.31 ± 0.17 vs. 0.42 ± 0.21; P < 0.01), TI (0.27 ± 0.09 vs. 0.31 ± 0.11; P = 0.03) and ICM (0.25 ± 0.11 vs. 0.31 ± 0.17; P = 0.04). In multivariate logistic regression analysis, higher SOAM (odds ratio, 0.780; 95% confidence interval, 0.619-0.961; P = 0.025) remained independently associated with lower risk of internal carotid artery aneurysm rupture. In addition, we found significant positive correlation of aneurysm dome size with SOAM (R = 0.224; P = 0.013) and PAD (0.269; P < 0.01). Our study also showed that age (R = 0.252; P = 0.036), Glasgow Coma Scale score (R = -0.706; P < 0.01), and TI (R = -0.249; P = 0.042) were independently correlated with modified Rankin Scale score on discharge. CONCLUSIONS Lower tortuosity might be a protective factor against internal carotid artery aneurysm rupture and poor outcome after subarachnoid hemorrhage. Higher tortuosity is correlated with internal carotid artery aneurysm growth.
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Affiliation(s)
- Roger M Krzyżewski
- Departments of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland.
| | - Kornelia M Kliś
- Departments of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Borys M Kwinta
- Departments of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Bartłomiej Łasocha
- Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Brzegowy
- Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
| | - Tadeusz J Popiela
- Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
| | - Jerzy Gąsowski
- Departments of Internal Medicine and Gerontology, Jagiellonian University Medical College, Kraków, Poland
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14
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Hvas CL, Hvas AM. Viscoelastic Testing in the Clinical Management of Subarachnoid Hemorrhage and Intracerebral Hemorrhage. Semin Thromb Hemost 2022; 48:828-841. [PMID: 36100233 DOI: 10.1055/s-0042-1756191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) are both debilitating and life-threatening incidents calling for immediate action and treatment. This review focuses on the applicability of viscoelastic testing (rotational thromboelastometry or thromboelastography [TEG]) in the management of SAH and ICH. A systematic literature search was performed in PubMed and EMBASE. Studies including patients with SAH or ICH, in which viscoelastic testing was performed, were identified. In total, 24 studies were included for analysis, and further subdivided into studies on SAH patients investigated prior to stenting or coiling (n = 12), ICH patients (n = 8) and studies testing patients undergoing stenting or coiling, or ischemic stroke patients undergoing thrombolysis or thrombectomy and developing ICH as a complication (n = 5). SAH patients had increased clot firmness, and this was associated with a higher degree of early brain injury and higher Hunt-Hess score. SAH patients with delayed cerebral ischemia had higher clot firmness than patients not developing delayed cerebral ischemia. ICH patients showed accelerated clot formation and increased clot firmness in comparison to healthy controls. Patients with hematoma expansion had longer clot initiation and lower platelet aggregation than patients with no hematoma expansion. During stent procedures for SAH, adjustment of antiplatelet therapy according to TEG platelet mapping did not change prevalence of major bleeding, thromboembolic events, or functional outcome. Viscoelastic testing prior to thrombolysis showed conflicting results in predicting ICH as complication. In conclusion, viscoelastic testing suggests hypercoagulation following SAH and ICH. Further investigation of the predictive value of increased clot firmness in SAH seems relevant. In ICH, the prediction of hematoma expansion and ICH as a complication to thrombolysis might be clinically relevant.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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15
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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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16
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Wang X, Zhang Y, Chong W, Hai Y, Wang P, Deng H, You C, Fang F. Association of Rebleeding and Delayed Cerebral Ischemia with Long-term Mortality Among 1-year Survivors After Aneurysmal Subarachnoid Hemorrhage. Curr Neurovasc Res 2022; 19:282-292. [PMID: 35996234 DOI: 10.2174/1567202619666220822105510] [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: 06/16/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE The potential impact of rebleeding and Delayed Cerebral Ischemia (DCI) on long-term survival in patients with aneurysmal subarachnoid hemorrhage (aSAH) remained unclear. This study aimed to investigate whether DCI and rebleeding increase the risk of long-term all-cause mortality in patients with aSAH who survived the follow-up period of one year. METHODS We retrospectively collected data on patients with atraumatic aSAH who were still alive 12 months after aSAH occurrence between December 2013 and June 2019 from the electronic health system. Patients were then classified by the occurrence of rebleeding or DCI during hospitalization. Death records were obtained from an administrative database, the Chinese Household Registration Administration System, until April 20, 2021. Multivariable Cox proportional hazards models were used to compare overall survival in different groups. Sensitivity analysis was performed with propensity-score matching (PSM). RESULTS A total of 2,607 patients were alive one year after aSAH. The crude annual death rate from any cause among patients who had rebleeding (7.2 per 100 person-years) and patients who had DCI (3.7 per 100 person-years) during hospitalization was higher than that of patients with neither event (2.1 per 100 person-years). Multivariate analysis showed that rebleeding is an independent risk factor for long-term mortality (adjusted hazard ratio (aHR), 2.37; 95% confidence interval (CI), 1.47- 3.81). DCI was an independent prognostic factor of poorer overall survival (aHR, 2.09; 95% CI, 1.54-2.84). CONCLUSION Amongst patients alive one year after aSAH, rebleeding and DCI during hospitalization were independently associated with higher rates of long-term mortality.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, 19144 USA
| | - Yang Hai
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19144 USA
| | - Peng Wang
- Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Haidong Deng
- Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fang Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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17
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Spelle L, Herbreteau D, Caroff J, Barreau X, Ferré JC, Fiehler J, Januel AC, Costalat V, Liebig T, Bourcier R, Möhlenbruch MA, Berkefeld J, Weber W, Mihalea C, Ikka L, Ozanne A, Cognard C, Narata AP, Bibi RE, Gauvrit JY, Raoult H, Velasco S, Buhk JH, Chalumeau V, Bester M, Desal H, du Mesnil de Rochemont R, Bohner G, Fischer S, Gallas S, Biondi A, Grimaldi L, Moret J, Byrne J, Pierot L. CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS): 12-month angiographic results of a multicenter study. J Neurointerv Surg 2022:neurintsurg-2022-018749. [PMID: 35882550 DOI: 10.1136/neurintsurg-2022-018749] [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: 02/08/2022] [Accepted: 05/19/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS) study has shown that the endovascular treatment of ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) is safe and effective and provides protection against rebleeding at 1 month and 1 year. The 12-month angiographic follow-up is an important endpoint of the study. METHODS The CLARYS study is a prospective multicenter study conducted in 13 European centers. The study enrolled 60 patients with 60 ruptured aneurysms of the anterior and posterior circulation. The study was conducted with an independent assessment of safety outcomes and imaging. RESULTS Sixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. Fifty-three aneurysms (88.3%) had a broad base with a dome to neck ratio <2 (mean 1.6). Of these, 46 patients were evaluated by an independent core laboratory with follow-up imaging performed at 12 months or before eventual retreatment. At 1 year, 19/46 aneurysms (41.3%) were completely occluded (Raymond-Roy grade I), 21/46 (45.7%) had a residual neck and 6/46 (13.0%) had residual aneurysm filling. Adequate occlusion was reported in 40/46 (87%) aneurysms. Six patients underwent target aneurysm retreatment. CONCLUSIONS The CLARYS study has previously shown that the use of the WEB in the endovascular treatment of ruptured bifurcation aneurysms provides effective protection against rebleeding with a good safety profile. The angiographic occlusion rates at 1 year reported here are comparable to those already seen in previous multicenter studies which primarily included unruptured aneurysms.
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Affiliation(s)
- Laurent Spelle
- NEURI Brain Vascular Center, Interventional Neuroradiology, Bicetre University Hospital, Le Kremlin-Bicetre, France .,Paris-Saclay University Faculty of Medicine, Le Kremlin-Bicetre, France
| | - Denis Herbreteau
- Department of Interventional Neuroradiology, Regional University Hospital, Tours, France
| | - Jildaz Caroff
- NEURI Brain Vascular Center, Interventional Neuroradiology, Bicetre University Hospital, Le Kremlin-Bicetre, France.,Assistance Publique - Hopitaux de Paris, Paris, France
| | - Xavier Barreau
- Department of Neuroradiology, Pellegrin University Hospital, Bordeaux, France
| | | | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne-Christine Januel
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Pierre Paul Riquet, Toulouse, France
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Thomas Liebig
- Department of Neuroradiology, Ludwig Maximilians University, Munich Faculty of Medicine, Munchen, Germany
| | - Romain Bourcier
- Department of Neuroradiology, Regional University Hospital, Nantes, France
| | - Markus A Möhlenbruch
- Department of Neuroradiology, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Joachim Berkefeld
- Institut für Neuroradiologie, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt am Main, Germany
| | - Werner Weber
- Department of Neuroradiology, Ruhr-Universitat Bochum Medizinische Fakultat, Bochum, Germany
| | - Cristian Mihalea
- NEURI Brain Vascular Center, Interventional Neuroradiology, Bicetre University Hospital, Le Kremlin-Bicetre, France.,Assistance Publique - Hopitaux de Paris, Paris, France
| | - Léon Ikka
- NEURI Brain Vascular Center, Interventional Neuroradiology, Bicetre University Hospital, Le Kremlin-Bicetre, France.,Assistance Publique - Hopitaux de Paris, Paris, France
| | - Augustin Ozanne
- NEURI Brain Vascular Center, Interventional Neuroradiology, Bicetre University Hospital, Le Kremlin-Bicetre, France.,Assistance Publique - Hopitaux de Paris, Paris, France
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Pierre Paul Riquet, Toulouse, France
| | - Ana Paula Narata
- Department of Interventional Neuroradiology, Regional University Hospital, Tours, France
| | - Richard Edwige Bibi
- Department of Interventional Neuroradiology, Regional University Hospital, Tours, France
| | - Jean-Yves Gauvrit
- Department of Neuroradiology, Regional University Hospital, Rennes, France
| | - Hélène Raoult
- Department of Neuroradiology, Regional University Hospital, Rennes, France
| | - Stéphane Velasco
- Department of Radiology, Regional University Hospital, Poitiers, France
| | - Jan-Hendrik Buhk
- Department of Neuroradiology, Asklepios Hospital Group, Hamburg, Germany
| | - Vanessa Chalumeau
- NEURI Brain Vascular Center, Interventional Neuroradiology, Bicetre University Hospital, Le Kremlin-Bicetre, France.,Assistance Publique - Hopitaux de Paris, Paris, France
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hubert Desal
- Department of Neuroradiology, Regional University Hospital, Nantes, France
| | | | - Georg Bohner
- Neuroradiology, Charite Universitatsmedizin, Berlin, Germany
| | - Sebastian Fischer
- Department of Neuroradiology, Ruhr-Universitat Bochum Medizinische Fakultat, Bochum, Germany
| | - Sophie Gallas
- NEURI Brain Vascular Center, Interventional Neuroradiology, Bicetre University Hospital, Le Kremlin-Bicetre, France.,Assistance Publique - Hopitaux de Paris, Paris, France
| | - Alessandra Biondi
- Department of Neuroradiology and Endovascular Therapy, Jean Minjoz University Hospital, Besancon, France
| | - Lamiae Grimaldi
- Clinical Research Unit AP-HP, Paris-Saclay University Faculty of Medicine, Le Kremlin-Bicetre, France.,CESP Anti-Infective Evasion and Pharmacoepidemiology Team, Université de Versailles Saint-Quentin-en-Yvelines UFR des Sciences de la Santé Simone Veil, Montigny-Le-Bretonneux, France
| | - Jacques Moret
- NEURI Brain Vascular Center, Interventional Neuroradiology, Bicetre University Hospital, Le Kremlin-Bicetre, France.,Paris-Saclay University Faculty of Medicine, Le Kremlin-Bicetre, France
| | - James Byrne
- Department of Neuroradiology, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison Blanche, Reims, France.,Champagne-Ardenne University, Reims, France
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18
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Calviere L, Gathier CS, Rafiq M, Koopman I, Rousseau V, Raposo N, Albucher JF, Viguier A, Geeraerts T, Cognard C, Rinkel GJE, Vergouwen MDI, Olivot JM. Rebleeding After Aneurysmal Subarachnoid Hemorrhage in Two Centers Using Different Blood Pressure Management Strategies. Front Neurol 2022; 13:836268. [PMID: 35280266 PMCID: PMC8905619 DOI: 10.3389/fneur.2022.836268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background High systolic blood pressure (SBP) after aneurysmal subarachnoid hemorrhage (aSAH) has been associated with an increased risk of rebleeding. It remains unclear if an SBP lowering strategy before aneurysm treatment decreases this risk without increasing the risk of a delayed cerebral ischemia (DCI). Therefore, we compared the rates of in-hospital rebleeding and DCI among patients with aSAH admitted in two tertiary care centers with different SBP management strategies. Methods Retrospective cohort study. Consecutive patients from Utrecht and Toulouse admitted within 24 h after the aSAH onset were enrolled. In Toulouse, the target SBP before aneurysm treatment was ≤140 mm Hg, while, in Utrecht, an increased SBP was only treated in extreme situations. We compared SBP levels, the incidence of rebleeding within 24 h after admission, and DCI during hospitalization. Results We enrolled 373 patients in Utrecht and 149 in Toulouse. The mean SBP on admission was similar but lower in Toulouse 4 h after admission (127.3 ± 17.4 vs. 138. ± 25.7 mmHg; p < 0.0001). After a median delay of 3.7 h (IQR, 2.3-7.4) from admission, 4 patients (3%) in Toulouse vs. 29 (8%) in Utrecht experienced a rebleeding. After adjustment for Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH) score, aneurysm size, age, and delay from ictus to admission, the HR was 0.66 (95% CI: 0.23-1.92). Incidence of DCI was 18% in Toulouse and 25% in Utrecht (adjusted OR, 0.68; 95% CI: 0.41-1.11). Conclusion Our results suggest that an intensive SBP lowering strategy between admission and aneurysm treatment does not decrease the risk of rebleeding and does not increase the risk of DCI compared to a more conservative strategy.
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Affiliation(s)
- Lionel Calviere
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
| | - Celine S. Gathier
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | | | - Inez Koopman
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Vanessa Rousseau
- MeDatAS-CIC, CIC1436, Centre Hospitalier Universitaire, Toulouse, France
| | - Nicolas Raposo
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
| | - Jean François Albucher
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
| | - Alain Viguier
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
| | - Thomas Geeraerts
- Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France.,Department of Anesthesiology and Critical Care, CHU Toulouse, Toulouse, France
| | | | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Jean-Marc Olivot
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
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19
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Torregrossa F, Grasso G. Therapeutic Approaches for Cerebrovascular Dysfunction After Aneurysmal Subarachnoid Hemorrhage: An Update and Future Perspectives. World Neurosurg 2022; 159:276-287. [PMID: 35255629 DOI: 10.1016/j.wneu.2021.11.096] [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: 09/28/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe subtype of stroke occurring at a relatively young age with a significant socioeconomic impact. Treatment of aSAH includes early aneurysm exclusion, intensive care management, and prevention of complications. Once the aneurysm rupture occurs, blood spreading within the subarachnoid space triggers several molecular pathways causing early brain injury and delayed cerebral ischemia. Pathophysiologic mechanisms underlying brain injury after aSAH are not entirely characterized, reflecting the difficulties in identifying effective therapeutic targets for patients with aSAH. Although the improvements of the last decades in perioperative management, early diagnosis, aneurysm exclusion techniques, and medical treatments have increased survival, vasospasm and delayed cerebral infarction are associated with high mortality and morbidity. Clinical practice can rely on a few specific therapeutic agents, such as nimodipine, a calcium-channel blocker proved to reduce severe neurologic deficits in these patients. Therefore, new pharmacologic approaches are needed to improve the outcome of this life-threatening condition, as well as a tailored rehabilitation plan to maintain the quality of life in aSAH survivors. Several clinical trials are investigating the efficacy and safety of emerging drugs, such as magnesium, clazosentan, cilostazol, interleukin 1 receptor antagonists, deferoxamine, erythropoietin, and nicardipine, and continuous lumbar drainage in the setting of aSAH. This narrative review focuses on the most promising therapeutic interventions after aSAH.
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Affiliation(s)
- Fabio Torregrossa
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy.
| | - Giovanni Grasso
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
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ABO blood group in aneurysmal subarachnoid haemorrhage-a pilot study. Acta Neurochir (Wien) 2022; 164:507-515. [PMID: 35039955 DOI: 10.1007/s00701-021-05079-5] [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: 10/06/2021] [Accepted: 12/02/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE To evaluate the distribution and impact of ABO blood group on the baseline characteristics and clinical outcomes of patients presenting with aneurysmal subarachnoid haemorrhage (aSAH). METHODS Retrospective, single-centre study of patients admitted to a neurosurgical department in the UK, with a diagnosis of spontaneous subarachnoid haemorrhage between May 2014 and January 2020. Patients were categorised by ABO blood type and by Rhesus status. Clinical outcomes such as initial bleeding, rebleeding, delayed cerebral ischaemia (DIND) and venous thromboembolism were analysed in relation to the size of their association with ABO blood type. Hospital mortality rate, Glasgow Outcome Score (GOS) - at discharge and 3 months post-ictus, requirement for ventriculoperitoneal shunt insertion, discharge destination and inpatient length of stay were also considered. RESULTS Four-hundred twelve adult patients admitted with aSAH were included in our analysis. The distribution of ABO group or Rhesus status in our cohort did not differ significantly from the general population in the UK. Blood group A patients had a significantly increased risk of developing DIND, compared with non-blood group A patients (OR, 1.88 [95% CI: 1.10-3.21]). CONCLUSIONS ABO blood type appears to influence aSAH sequelae. Blood group A patients are at highest risk of DIND following aSAH.
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21
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Flow Diverter Treatment of Ruptured Basilar Artery Perforator Aneurysms. Clin Neuroradiol 2022; 32:783-789. [PMID: 35059755 PMCID: PMC9424161 DOI: 10.1007/s00062-021-01133-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/18/2021] [Indexed: 11/27/2022]
Abstract
Purpose Ruptured basilar artery perforator aneurysms (BAPAs) represent a very rare cause of subarachnoid hemorrhage and an under-reported subtype of cerebral aneurysm. There is no consensus for the optimal treatment strategy (conservative vs. surgical vs. various endovascular approaches). We aim to present a multicenter experience of BAPA treatment using flow-diverter (FD) stents. Methods At five tertiary neurovascular centers, all cases of ruptured BAPAs treated by FD were retrospectively collected. Baseline imaging and clinical characteristics, complications, as well as early and long-term angiographic and clinical outcome (mRS) were analyzed. Results Eighteen patients (mean age, 57 years; SD, ±10.7 years) with acute SAH related to a BAPA were treated using 18 FD stents. Aneurysms were detected on initial imaging study in 28%; delayed diagnosis was triggered by clinical deterioration due to rebleeding in 15%. No rebleeding after FD was seen, 28% developed FD-related ischemic complications. At long term (n = 16), overall mortality was 13% (2/16), and favorable outcome (mRS 0–2) was 81% (13/16). All BAPAs (n = 13) were completely occluded at long-term angiographic follow-up. Conclusion In our multicenter experience, FD treatment of ruptured BAPAs appears to have comparable safety and efficacy outcomes to FD treatment of other ruptured posterior circulation aneurysms as well as to the conservative management of BAPAs. This treatment strategy for a ruptured BAPA achieved a high rate of angiographic occlusion and favorable clinical outcome; however, as the conservative management also seems to offer similar clinical outcomes an individualized treatment decision is warranted. Future prospective studies comparing both approaches are required. Supplementary Information The online version of this article (10.1007/s00062-021-01133-y) contains supplementary material, which is available to authorized users.
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Fuentes AM, Stone McGuire L, Amin-Hanjani S. Sex Differences in Cerebral Aneurysms and Subarachnoid Hemorrhage. Stroke 2022; 53:624-633. [PMID: 34983239 DOI: 10.1161/strokeaha.121.037147] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sex differences in cerebral aneurysm occurrence and characteristics have been well described. Although sex differences in outcomes following ischemic stroke have been identified, the effect of sex on outcomes following hemorrhagic stroke, and in particular, aneurysm treatment has been less studied. We describe the current state of knowledge regarding the impact of sex on treatment and outcomes of cerebral aneurysms. Although prior studies suggest that aneurysm prevalence and progression may be related to sex, we did not find clear evidence that outcomes following subarachnoid hemorrhage vary based on sex. Last, we identify areas for future research that could enhance understanding of the role sex plays in this context.
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Liu T, Wu L, Xue R, Ding H. Efficacy and safety of tranexamic acid in aneurysmal subarachnoid hemorrhage: A meta-analysis of randomized controlled trials. Am J Emerg Med 2021; 50:646-653. [PMID: 34879481 DOI: 10.1016/j.ajem.2021.09.051] [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: 07/31/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Tranexamic acid, as a traditional hemostatic agent, is commonly used to treat or prevent excessive blood loss. However, the role of tranexamic acid in promoting good clinical outcomes and reducing mortality and risk of adverse events during the treatment of aneurysmal subarachnoid hemorrhage remains unclear. METHODS In strict accordance with the inclusion and exclusion criteria, Cochrane Library, Embase, Web of Science, and PubMed databases were assessed for randomized controlled trials (published between 1980 and 2021). Data were analyzed using STATA 16.0 and RevMan 5.3. In addition, the fixed-effects model (M-H method) and effect size (risk difference; RD) were used as a pooled measure to combine data. We also performed a post hoc sensitivity analysis and subgroup analysis to evaluate each outcome with low heterogeneity. RESULTS A meta-analysis revealed that although tranexamic acid was related to less rebleeding (RD = -0.06; 95% CI [-0.09, -0.03]; P = 0.0006), there is evidence that it has no an effect on good clinical outcomes or mortality (RD = -0.01; 95% CI [-0.05, 0.02]; P = 0.51; RD = 0.00; 95% CI [-0.03, 0.04]; P = 0.91). Tranexamic acid was associated with increased hydrocephalus (RD = 0.04; 95% CI [0.01, 0.08]; P = 0.02) and seizure (RD = 0.04; 95% CI [0.00, 0.08]; P = 0.05). The incidence of thromboembolic complications or delayed cerebral ischemia was not different in the two groups (RD = -0.01; 95% CI [-0.04, 0.03]; P = 0.62; RD = 0.00; 95% CI [-0.03, 0.03]; P = 0.96), and significant drug-related overall adverse events were identified (RD = 0.02; 95% CI [0.00, 0.04]; P = 0.03). CONCLUSIONS These findings indicate that the routine use of tranexamic acid is not suggested for patients with aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Tao Liu
- Department of Neurosurgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, China.
| | - Lingqin Wu
- Zhoushan Women and Children Hospital, Zhoushan 330902, China
| | - Renmin Xue
- Department of Cell Biology, Capital Medical University, Beijing 100069, China
| | - Huiru Ding
- Department of Endocrinology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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Al-Mufti F, Mayer SA, Kaur G, Bassily D, Li B, Holstein ML, Ani J, Matluck NE, Kamal H, Nuoman R, Bowers CA, S Ali F, Al-Shammari H, El-Ghanem M, Gandhi C, Amuluru K. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism. Neuroradiol J 2021; 34:542-551. [PMID: 34476991 PMCID: PMC8649190 DOI: 10.1177/19714009211024633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Daniel Bassily
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Boyi Li
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Matthew L Holstein
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Jood Ani
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Nicole E Matluck
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Maria Fareri Children’s Hospital, Westchester Medical Center, Valhalla, USA
| | | | - Faizan S Ali
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Hussein Al-Shammari
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA
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Kim D, Pyen J, Whang K, Cho S, Jang Y, Kim J, Koo Y, Choi J. Factors associated with rebleeding after coil embolization in patients with aneurysmal subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2021; 24:36-43. [PMID: 34695883 PMCID: PMC8984641 DOI: 10.7461/jcen.2021.e2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/20/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Aneurysmal subarachnoid hemorrhage (aSAH) has a high mortality rate, and hemorrhage amounts and perioperative rebleeding importantly determines prognosis. However, despite adequate treatment, prognosis is poor in many ruptured aneurysm cases. In this study, we identified and evaluated factors related to perioperative rebleeding in patients with aSAH. Methods The medical and surgical records of 166 patients that underwent endovascular embolization for a ruptured cerebral aneurysm at a single institution from 2014 to 2016 were retrospectively analyzed to identify risk factors of rebleeding. All patients were examined for risk factors and evaluated for increased hemorrhage by brain computed tomography at 3 days after surgery. Results This series included 54 men (32.5%) and 112 women (67.5%) of mean age 58.3±14.3 years. After procedures, 26 patients (15.7%) experienced rebleeding, and 1 of these (0.6%) experienced an intraoperative aneurysmal rupture. External ventricular drainage (EVD) (odds ratio [OR] 5.389, [95% confidence interval (CI) 1.171- 24.801]) and modified Fisher grade (OR 2.037, [95% CI 1.077-3.853]) were found to be independent risk factors of rebleeding, and perioperative rebleeding was strongly associated with patient outcomes (p<0.001). Conclusions We concluded the rebleeding risk after aSAH is greater in patients with large hemorrhage amounts and a high pre-operative modified Fisher grade, and thus, we caution neurosurgeons should take care in such cases.
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Affiliation(s)
- Donghee Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jinsu Pyen
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sungmin Cho
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yeongyu Jang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongyeon Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Younmoo Koo
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongwook Choi
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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Best Motor Response Predicts Favorable Outcome for "True" WFNS Grade V Patients with Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106075. [PMID: 34481320 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106075] [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: 08/01/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The universal application of ultra-early surgery for World Federation of Neurological Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (aSAH) patients may lead to the increased implementation of unnecessary treatment. Therefore, this study aimed to refine the patient selection process for timely definitive treatment. METHODS From January 2011 to March 2020, a total of 517 aSAH patients were treated at our institution. Among these, 177 aSAH patients with WFNS grade V on admission were identified from our database. Patients with improved grades in response to the initial supportive treatment, with clinical or radiological signs of herniation, and with irreversible signs of brain damage such as bilaterally dilated pupils and global ischemia on follow-up CT scan were excluded. The outcome of definitive treatment for 54 patients without herniation who remained with WFNS grade V after the initial supportive treatment were analyzed to seek any factor for a favorable outcome (modified Rankin scale 0-2). RESULTS Among 54 patients, 19 (35.2%) had a favorable outcome after a definitive treatment. Multivariate logistic regression analysis showed that the best motor response (BMR) 4 on Glasgow Coma Scale was significantly associated with favorable outcomes (odds ratio, 3.76; 95% confidence interval, 1.09-13.0, p = 0.03). The positive predictive value of BMR 4 was 48.3%. CONCLUSIONS Albeit being simple, BMR 4 may facilitate the prompt aggressive treatment for patients with WFNS grade V including those with "true" grade V who do not have any clinical and radiological signs of herniation.
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27
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Hantsche A, Wilhelmy F, Kasper J, Wende T, Hamerla G, Rasche S, Meixensberger J, Lindner D. Early prophylactic anticoagulation after subarachnoid hemorrhage decreases systemic ischemia and improves outcome. Clin Neurol Neurosurg 2021; 207:106809. [PMID: 34274657 DOI: 10.1016/j.clineuro.2021.106809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 06/23/2021] [Accepted: 07/07/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND In neurosurgical perioperative treatment, especially in connection with subarachnoid hemorrhage (SAH), the prophylactic anticoagulation (AC) regimen is still considered controversial. The goal of this retrospective study was to assess how the time point of low-molecular-weight heparin (LMWH) initiation (ToH) affects ischemic and hemorrhagic events after SAH. METHODS 370 patients who received acute treatment for non-traumatic SAH between 2011 and 2018 were included, and 208 patients were followed up after 12 months. We assessed how the ToH affects ischemic and hemorrhagic events as well as outcome scores. Statistical analysis was performed using the Mann-Whitney U-Test, the chi-squared test, Fisher's exact test, and univariate binomial logistic regression. P-values below 0.05 were considered statistically significant. RESULTS The incidence of systemic ischemia was 4.6%, cerebral ischemia 33.5%, and intracranial rebleeding 14.6%. Delaying ToH (measured in hours) increases systemic ischemia (p = 0.009). The odds ratio for the impact of delayed anticoagulation on systemic ischemia is 1.013 per hour (95%CI of OR 1.001-1.024). ToH has no influence on cerebral ischemia or intracranial rebleeding. Early anticoagulation was associated with a more favorable Glasgow Outcome Score 12 months after discharge (ToH within 48 h: p = 0.006). ToH did not affect mortality or readmission rates. CONCLUSIONS Initiating prophylactic AC with LMWH later than 48 h after aneurysm repair or admission impairs outcomes 12 months after discharge. It might be safe for patients with non-traumatic SAH to be anticoagulated with prophylactic doses of heparin within 24 h after admission or the treatment of source of bleeding (SoB). Early AC with prophylactic LMWH does not promote rebleeding.
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Affiliation(s)
- Annika Hantsche
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Florian Wilhelmy
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany.
| | - Johannes Kasper
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Tim Wende
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Gordian Hamerla
- University Hospital Leipzig, Division of Neuroradiology, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Stefan Rasche
- University Hospital Leipzig, Department of Anesthesiology and Intensive Care, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Jürgen Meixensberger
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Dirk Lindner
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
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Tawk RG, Hasan TF, D'Souza CE, Peel JB, Freeman WD. Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage. Mayo Clin Proc 2021; 96:1970-2000. [PMID: 33992453 DOI: 10.1016/j.mayocp.2021.01.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/27/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (<7 mm) are less susceptible to rupture, aneurysms larger than 7 mm should be treated on a case-by-case basis with consideration of additional risk factors of aneurysmal growth and rupture. However, this distinction is outdated. The PHASES score, which comprises data pooled from several prospective studies, provides precise estimates by considering not only the aneurysm size but also other variables, such as the aneurysm location. The International Study of Unruptured Intracranial Aneurysms is the largest observational study on the natural history of UIAs, providing the foundation to the current guidelines for the management of UIAs. Although SAH accounts for only 3% of all stroke subtypes, it is associated with considerable burden of morbidity and mortality. The initial management is focused on stabilizing the patient in the intensive care unit with close hemodynamic and serial neurologic monitoring with endovascular or open surgical aneurysm treatment to prevent rebleeding. Since the results of the International Subarachnoid Aneurysm Trial, treatment of aneurysmal SAH has shifted from surgical clipping to endovascular coiling, which demonstrated higher odds of survival free of disability at 1 year after SAH. Nonetheless, aneurysmal SAH remains a public health hazard and is associated with high rates of disability and death.
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Affiliation(s)
- Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport
| | | | | | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL; Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Critical Care, Mayo Clinic, Jacksonville, FL
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Ohbuchi H, Hagiwara S, Arai N, Yoneyama T, Takahashi Y, Inazuka M, Kubota Y, Chernov M, Kasuya H. Optimal timing and safety of the external ventricular drainage in patients with high-grade aneurysmal subarachnoid hemorrhage treated with endovascular coiling. J Clin Neurosci 2021; 88:63-69. [PMID: 33992206 DOI: 10.1016/j.jocn.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 02/11/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
The presented retrospective analysis has evaluated the optimal timing and safety of external ventricular drainage (EVD) for acute hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH). The study cohort comprised 102 patients, 49 of whom underwent EVD at 3-120 h (mean, 16 h) after the clinical onset of aSAH, either before (N = 27) or after (N = 22) ruptured aneurysm coiling. Among those treated with EVD, favorable and fair outcomes at discharge (modified Rankin Scale [mRS] scores 0-3) were noted in 14 (29%) and unfavorable (mRS scores 4-6) in 35 (71%). The former was more common among women (P = 0.019) and patients without chronic arterial hypertension (P = 0.028). The cut-off value for optimal timing of EVD was defined at 13 h after the onset of aSAH. Favorable and fair outcomes were more frequent after early (≤13 h; N = 30) than late (>13 h; N = 19) EVD (40% vs. 11%; P = 0.026), whereas did not differ significantly between those in whom such procedure was done before or after ruptured aneurysm coiling (19% vs. 41%; P = 0.083). In the entire study cohort, 2 patients had re-rupture of the aneurysm, and while both of them were treated with EVD, neither case of complication was directly associated with the procedure and, in fact, preceded it. In conclusion, EVD for management of acute hydrocephalus in patients with high-grade aSAH should be preferably applied within 13 h after the clinical onset of stroke, which may be considered sufficiently safe regardless whether it is performed before or after ruptured aneurysm coiling.
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Affiliation(s)
- Hidenori Ohbuchi
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo.
| | - Shinji Hagiwara
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Naoyuki Arai
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Taku Yoneyama
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Yuichi Takahashi
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo; Department of Neurosurgery, Moriya Daiichi General Hospital, Ibaraki, Japan
| | - Mayuko Inazuka
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Yuichi Kubota
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Mikhail Chernov
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Medical Center East, Tokyo Women's Medical University, Tokyo
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Sorteberg A, Romundstad L, Sorteberg W. Timelines and rebleeds in patients admitted into neurosurgical care for aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 2021; 163:771-781. [PMID: 33409740 PMCID: PMC7886745 DOI: 10.1007/s00701-020-04673-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022]
Abstract
Background Mortality and morbidity of aneurysmal subarachnoid haemorrhage (aSAH) remain high, and prognosis is influenced by multiple non-modifiable factors such as aSAH severity. By analysing the chronology of aSAH management, we aim at identifying modifiable factors with emphasis on the occurrence of rebleeds in a setting with 24/7 surgical and endovascular availability of aneurysm repair and routine administration of tranexamic acid. Methods Retrospective analysis of institutional quality registry data of aSAH cases admitted into neurosurgical care during the time period 01 January 2013–31 December 2017. We registered time and mode of aneurysm repair, haemorrhage patterns, course of treatment, mortality and functional outcome. Rebleeding was scored along the entire timeline from ictus to discharge from the primary stay. Results We included 544 patients (368, 67.6% female), aged 58 ± 14 years (range 1–95 years). Aneurysm repair was performed in 486/544 (89.3%) patients at median 7.4 h after arrival and within 3, 6, 12 and 24 h in 26.8%, 44.7%, 73.0% and 96.1%, respectively. There were circadian variations in time to repair and in rebleeds. Rebleeding prior to aneurysm repair occurred in 9.7% and increased with aSAH severity and often in conjunction with patient relocations or interventions. Rebleeds occurred more often during surgical repair outside regular working hours, whereas rebleeds after repair (1.8%) were linked to endovascular repair. Conclusions The risk of rebleed is imminent throughout the entire timeline of aSAH management even with ultra-early aneurysm repair. Several modifiable factors can be linked to the occurrence of rebleeds and they should be identified and optimised within neurosurgical departments. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-020-04673-3.
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Shen J, Yu J, Huang S, Mungur R, Huang K, Pan X, Yu G, Xie Z, Zhou L, Liu Z, Cheng D, Pan J, Zhan R. Scoring Model to Predict Functional Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2021; 12:601996. [PMID: 33679575 PMCID: PMC7930831 DOI: 10.3389/fneur.2021.601996] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as World Federation of Neurosurgical Societies (WFNS) grades IV–V have high rates of disability and mortality. The objective of this study was to accurately prognosticate the outcomes of patients with poor-grade aSAH by developing a new scoring model. Methods: A total of 147 poor-grade aSAH patients in our center were enrolled. Risk variables identified by multivariate logistic regression analysis were used to devise a scoring model (total score, 0–9 points). The scores were estimated on the basis of β coefficients. A cohort of 68 patients from another institute was used to validate the model. Results: Multivariate logistic regression analysis revealed that modified Fisher grade >2 [odds ratio [OR], 2.972; P = 0.034], age ≥65 years (OR, 3.534; P = 0.006), conservative treatment (OR, 5.078; P = 0.019), WFNS grade V (OR, 2.638; P = 0.029), delayed cerebral ischemia (OR, 3.170; P = 0.016), shunt-dependent hydrocephalus (OR, 3.202; P = 0.032), and cerebral herniation (OR, 7.337; P < 0.001) were significant predictors for poor prognosis [modified Rankin Scale [mRS] ≥3]. A scoring system was constructed by the integration of these factors and divided the poor-grade aSAH patients into three categories: low risk (0–1 points), intermediate risk (2–3 points), and high risk (4–9 points), with predicted risks of poor prognosis of 11, 52, and 87%, respectively (P < 0.001). The area under the curve in the derivation cohort was 0.844 (95% CI, 0.778–0.909). The AUC in the validation cohort was 0.831 (95% CI, 0.732–0.929). Conclusions: The new scoring model can improve prognostication and help decision-making for subsequent complementary treatment in patients with aSAH.
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Affiliation(s)
- Jie Shen
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianbo Yu
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Sicong Huang
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Rajneesh Mungur
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Kaiyuan Huang
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xinfa Pan
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Guofeng Yu
- Department of Neurosurgery, Quzhou People's Hospital, Quzhou, China
| | - Zhikai Xie
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Lihui Zhou
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zongchi Liu
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Dexin Cheng
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianwei Pan
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Renya Zhan
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
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Optimal Hemodynamic Parameters for Brain-injured Patients in the Clinical Setting: A Narrative Review of the Evidence. J Neurosurg Anesthesiol 2021; 34:288-299. [PMID: 33443353 DOI: 10.1097/ana.0000000000000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/07/2020] [Indexed: 11/25/2022]
Abstract
Defining optimal hemodynamic targets for brain-injured patients is a challenging undertaking. The physiological interference observed in various intracranial pathologies can have varying effects on cerebral physiology at different time points. This narrative review provides an overview of cerebral autoregulatory physiology and common misconceptions, and examines the physiological considerations and clinical evidence for determining optimal hemodynamic parameters in acutely brain-injured patients with relevance to modern neuroanesthesia and neurocritical care practice.
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Etminan N, Macdonald RL. Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:135-169. [PMID: 33272393 DOI: 10.1016/b978-0-444-64034-5.00009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The worldwide incidence of spontaneous subarachnoid hemorrhage is about 6.1 per 100,000 cases per year (Etminan et al., 2019). Eighty-five percent of cases are due to intracranial aneurysms. The mean age of those affected is 55 years, and two-thirds of the patients are female. The prognosis is related mainly to the neurologic condition after the subarachnoid hemorrhage and the age of the patient. Overall, 15% of patients die before reaching the hospital, another 20% die within 30 days, and overall 75% are dead or remain disabled. Case fatality has declined by 17% over the last 3 decades. Despite the improvement in outcome probably due to improved diagnosis, early aneurysm repair, administration of nimodipine, and advanced intensive care support, the outcome is not very good. Even among survivors, 75% have permanent cognitive deficits, mood disorders, fatigue, inability to return to work, and executive dysfunction and are often unable to return to their premorbid level of functioning. The key diagnostic test is computed tomography, and the treatments that are most strongly supported by scientific evidence are to undertake aneurysm repair in a timely fashion by endovascular coiling rather than neurosurgical clipping when feasible and to administer enteral nimodipine. The most common complications are aneurysm rebleeding, hydrocephalus, delayed cerebral ischemia, and medical complications (fever, anemia, and hyperglycemia). Management also probably is optimized by neurologic intensive care units and multidisciplinary teams.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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Fully automated detection and segmentation of intracranial aneurysms in subarachnoid hemorrhage on CTA using deep learning. Sci Rep 2020; 10:21799. [PMID: 33311535 PMCID: PMC7733480 DOI: 10.1038/s41598-020-78384-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023] Open
Abstract
In aneurysmal subarachnoid hemorrhage (aSAH), accurate diagnosis of aneurysm is essential for subsequent treatment to prevent rebleeding. However, aneurysm detection proves to be challenging and time-consuming. The purpose of this study was to develop and evaluate a deep learning model (DLM) to automatically detect and segment aneurysms in patients with aSAH on computed tomography angiography. In this retrospective single-center study, three different DLMs were trained on 68 patients with 79 aneurysms treated for aSAH (2016–2017) using five-fold-cross-validation. Their outputs were combined to a single DLM via ensemble-learning. The DLM was evaluated on an independent test set consisting of 185 patients with 215 aneurysms (2010–2015). Independent manual segmentations of aneurysms in a 3D voxel-wise manner by two readers (neurosurgeon, radiologist) provided the reference standard. For aneurysms > 30 mm3 (mean diameter of ~ 4 mm) on the test set, the DLM provided a detection sensitivity of 87% with false positives (FPs)/scan of 0.42. Automatic segmentations achieved a median dice similarity coefficient (DSC) of 0.80 compared to the reference standard. Aneurysm location (anterior vs. posterior circulation; P = .07) and bleeding severity (Fisher grade ≤ 3 vs. 4; P = .33) did not impede detection sensitivity or segmentation performance. For aneurysms > 100 mm3 (mean diameter of ~ 6 mm), a sensitivity of 96% with DSC of 0.87 and FPs/scan of 0.14 were obtained. In the present study, we demonstrate that the proposed DLM detects and segments aneurysms > 30 mm3 in patients with aSAH with high sensitivity independent of cerebral circulation and bleeding severity while producing FP findings of less than one per scan. Hence, the DLM can potentially assist treating physicians in aSAH by providing automated detection and segmentations of aneurysms.
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Neifert SN, Chapman EK, Martini ML, Shuman WH, Schupper AJ, Oermann EK, Mocco J, Macdonald RL. Aneurysmal Subarachnoid Hemorrhage: the Last Decade. Transl Stroke Res 2020; 12:428-446. [PMID: 33078345 DOI: 10.1007/s12975-020-00867-0] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Emily K Chapman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Michael L Martini
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - William H Shuman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | | | - Eric K Oermann
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - R Loch Macdonald
- University Neurosciences Institutes, University of California San Francisco, Fresno Campus, Fresno, CA, 93701-2302, USA.
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D'Argento F, Pedicelli A, Ciardi C, Leone E, Scarabello M, Infante A, Alexandre A, Lozupone E, Valente I, Colosimo C. Intra- and inter-observer variability in intracranial aneurysm segmentation: comparison between CT angiography (semi-automated segmentation software stroke VCAR) and digital subtraction angiography (3D rotational angiography). LA RADIOLOGIA MEDICA 2020; 126:484-493. [PMID: 32902826 DOI: 10.1007/s11547-020-01275-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare size and morphologic features of three-dimensional aneurysm models, obtained with a semi-automated segmentation software (Stroke VCAR, GE, USA) from cerebral CT angiography (CTA) data, to three-dimensional aneurysm models obtained with digital subtraction angiography (DSA, with 3D rotational angiography acquisition-3DRA), considered as the reference standard. METHODS In this retrospective study, we reviewed 132 patients, with a total number of 137 intracranial aneurysm, who underwent CTA and subsequent DSA examination, supplemented with 3DRA. We compared neck length, short axis and long axis measured on 3DRA model to the same variables measured on 3D-CTA model by two blinded readers and to the automatic software dimensions. Therefore, statistics analysis assessed intra-observer and inter-observer variability and differences between patients with or without subarachnoid hemorrhage (SAH). RESULTS There were no significant differences in short-axis and long-axis measurements between 3D angiographic and 3D-CTA models, while comparison of neck lengths revealed a statistically significant difference, which tended to be greater for smaller neck lengths (partial volume effect and "kissing vessels" artifact). There were significant differences between manual and automatic data measured for the same three variables, and the presence of SAH did not affect aneurysm 3D reconstruction. Inter-observer agreement resulted moderate for neck length and substantial for short axis and long axis. CONCLUSION The examined 3D-CTA segmentation system is a reproducible procedure for aneurysm morphologic characterization and, in particular, for assessment of aneurysm sac dimensions, but considerable carefulness is required in neck length interpretation.
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Affiliation(s)
- F D'Argento
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - A Pedicelli
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - C Ciardi
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - E Leone
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - M Scarabello
- Postgraduate School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - A Infante
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A Alexandre
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - E Lozupone
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - I Valente
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - C Colosimo
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Instituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
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Enriquez CAG, Diestro JDB, Omar AT, Geocadin RG, Legaspi GD. Safety and Clinical Outcome of Good-Grade Aneurysmal Subarachnoid Hemorrhage in Non-Intensive Care Units. J Stroke Cerebrovasc Dis 2020; 29:105123. [PMID: 32912553 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105123] [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: 06/02/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND While patients with good grade aneurysmal subarachnoid hemorrhage are routinely admitted in intensive care units, critical care capacity in low-middle income countries (LMICs) is limited. In this study, we report the outcomes of good-grade SAH (Hunt and Hess grades I & II) patients admitted in ICU and non-ICU settings at a center in the Philippines and determine if site of care is predictive of outcome. METHODS We performed a retrospective study of all adults diagnosed with good-grade SAH in a five-year period. Patients were analyzed according to three groups based on site of care: Group A (>50% of length of stay in ICU), Group B (>50% of LOS in non-ICU), and Group C (100% of LOS in non-ICU). The primary outcome measures were in-hospital mortality and mRS score at discharge. The secondary outcome measures were complication rate and LOS. RESULTS A total of 242 patients was included in the cohort, which had a mean age of 51.16 years and a female predilection (64%). The rates of in-hospital mortality and favorable functional outcome at discharge were 0.82% and 93.8%, respectively, with no difference across groups. Delayed cerebral ischemia and infection were more frequently diagnosed in ICUs (p < 0.001), while rebleeding occurred more commonly in non-ICUs (p = 0.02). The median LOS was significantly longer in patients who developed complications. CONCLUSIONS Admission of good-grade aneurysmal SAH patients in non-ICU settings did not adversely affect both in-hospital mortality and functional outcome at discharge. Prospective, randomized studies may lead to changes in pattern of ICU utilization which are critical for LMICs.
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Affiliation(s)
- Clare Angeli G Enriquez
- Department of Neurosciences, University of the Philippines Manila - Philippine General Hospital, Manila, Philippines.
| | - Jose Danilo B Diestro
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Abdelsimar T Omar
- Department of Neurosciences, University of the Philippines Manila - Philippine General Hospital, Manila, Philippines
| | - Romergryko G Geocadin
- Department of Neurology, Neurosurgery, and Anesthesiology-Critical Care Medicine, Johns Hopkins School of Medicine, MD, USA
| | - Gerardo D Legaspi
- Department of Neurosciences, University of the Philippines Manila - Philippine General Hospital, Manila, Philippines
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Singh N, Jangra K, Regmi S, Singh A. Isolated Bradycardia During Aneurysmal Clipping: Rebleed or Trigeminocardiac Reflex? JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2020. [DOI: 10.1055/s-0040-1710298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractThe most common cause of nontraumatic subarachnoid hemorrhage is the rupture of intracranial aneurysm. After initial bleed, the risk of rebleeding is highest in the early postictal period and this rebleed is strongly associated with poor neurological outcome. The major goal of anesthesia in these surgeries is to prevent the rebleed. If rebleeding occurs prior to the craniotomy, it results in the acute rise of intracranial pressure and usually presents as bradycardia and hypertension (Cushing’s reflex). Here we reported a case where rebleeding presented unusually as isolated bradycardia without associated hypertension and was mistaken as trigeminocardiac reflex. The surgeon was informed about the event and they planned to proceed. After craniotomy, despite all the efforts the brain was persistently tight and surgery could not be completed. Postoperative scan showed rebleeding and the patient died after a few days in ICU.We highlighted in this case report the fact that isolated transient bradycardia may also be the presentation of rebleed with closed cranial vault. It is not always necessary to see all the features of Cushing’s traid in every patient. If bradycardia occurs before the craniotomy, the surgeon should be notified, the severity of bleed should be assessed, and further management should be planned according to the severity of bleed.
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Affiliation(s)
- Nidhi Singh
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sabina Regmi
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Apinderpreet Singh
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Thenier-Villa JL, Riveiro Rodríguez A, González-Vargas PM, Martínez-Rolán RM, Gelabert-González M, Badaoui Fernández A, Pou J, Conde Alonso C. Effects of external ventricular drainage decompression of intracranial hypertension on rebleeding of brain aneurysms: A fluid structure interaction study. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Survival and outcome in patients with aneurysmal subarachnoid hemorrhage in Glasgow coma score 3-5. Acta Neurochir (Wien) 2020; 162:533-544. [PMID: 31980948 DOI: 10.1007/s00701-019-04190-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/19/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outcome of early, aggressive management of aneurysmal subarachnoid hemorrhage (aSAH) in patients with Hunt and Hess grade V is hitherto limited, and we therefore present our results. METHODS Retrospective study analyzing the medical data of 228 aSAH patients in Glasgow Coma Score 3-5 admitted to our hospital during the years 2002-2012. Background and treatment variables were registered. Outcome was evaluated after 3 and 12 months. RESULTS We intended to treat 176 (77.2%) patients, but only 146 went on to aneurysm repair. Of 52 patients managed conservatively, 27 had abolished cerebral circulation around arrival and 25 were deemed unsalvageable. One-year overall mortality was 65.8% and most (84.7%) of the fatalities occurred within 30 days. One-year mortality was higher in patients > 70 years. Without aneurysm repair, mortality was 100%. After 1 year, 21.9% of all patients lived independently and 4.8% lived permanently in an institution. Outcome in the 78 survivors (34.2%) was favorable in 64.1% in terms of modified Rankin Scale score 0-2, and 85.9% of survivors were able to live at home. Return to work was low for all 228 patients with 14.0% of those employed prior to the hemorrhage having returned to paid work, and respectively, 26.3% in the subgroup of survivors. CONCLUSIONS Even with aggressive, early treatment, 1-year mortality is high in comatose aSAH patients with 65.8%. A substantial portion of the survivors have a favorable outcome at 1 year (64.1%, corresponding to 21.9% of all patients admitted) and 85.9% of the survivors could live at home alone or aided.
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The accuracy of aneurysm size in predicting rebleeding after subarachnoid hemorrhage: a meta-analysis. Neurol Sci 2020; 41:1843-1850. [DOI: 10.1007/s10072-020-04297-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/13/2020] [Indexed: 10/25/2022]
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Daou BJ, Koduri S, Thompson BG, Chaudhary N, Pandey AS. Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage. CNS Neurosci Ther 2019; 25:1096-1112. [PMID: 31583833 PMCID: PMC6776745 DOI: 10.1111/cns.13222] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 11/30/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic "triple-H" therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.
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Affiliation(s)
- Badih J. Daou
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Sravanthi Koduri
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | | | - Neeraj Chaudhary
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Aditya S. Pandey
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
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Horie N, Sato S, Kaminogo M, Morofuji Y, Izumo T, Anda T, Matsuo T. Impact of perioperative aneurysm rebleeding after subarachnoid hemorrhage. J Neurosurg 2019; 133:1401-1410. [PMID: 31518984 DOI: 10.3171/2019.6.jns19704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysm rebleeding is a major cause of death and morbidity in patients with aneurysmal subarachnoid hemorrhage (SAH). Recognizing the predictors of rebleeding might help to identify patients who will benefit from acute management. This study was performed to investigate the predictors of aneurysm rebleeding and their impact on clinical outcomes in the preoperative, intraoperative, and postoperative periods. METHODS The incidence of rebleeding, demographic data, and clinical data from 4933 patients with aneurysmal SAH beginning in the year 2000 were retrospectively analyzed in the Nagasaki SAH Registry Study. The authors performed multiple logistic regression analyses to identify the risk factors contributing to rebleeding and outcome after SAH. RESULTS Preoperative rebleeding occurred in 7.2% of patients. Patient age (p = 0.01), multiple aneurysms (p < 0.01), aneurysm size (p < 0.0001), and heart disease (p = 0.03) were significantly associated with preoperative rebleeding. Conversely, intraoperative rebleeding occurred in 11.2% of patients. Aneurysm location (anterior communicating artery [ACoA]), family history (p = 0.02), preoperative rebleeding (p < 0.01), and clipping/coiling (p < 0.0001) were significantly associated with intraoperative rebleeding. Interaction analysis showed that clipping significantly affected intraoperative rebleeding at the ACoA (OR 4.00; 95% CI 1.82-8.80; p < 0.001). Postoperative rebleeding occurred in 2.4% of patients. Coiling/clipping (p < 0.0001) and intraoperative rebleeding (p < 0.01) were significantly associated with postoperative rebleeding. Rebleeding in all time periods examined significantly contributed to the clinical outcome after SAH. CONCLUSIONS Aneurysm rebleeding after SAH has specific characteristics in the preoperative, intraoperative, and postoperative periods, and all of these characteristics contribute to the clinical outcome. The ACoA has a higher risk of intraoperative rebleeding, and endovascular coiling could be a good candidate in terms of techniques for preventing intraoperative rebleeding, although complete aneurysm obliteration should be accomplished.
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Affiliation(s)
| | - Shuntaro Sato
- 2Clinical Research Center, Nagasaki University School of Medicine, Nagasaki, Japan
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Duangthongphon P, Souwong B, Munkong W, Kitkhuandee A. Results of a Preventive Rebleeding Protocol in Patients with Ruptured Cerebral Aneurysm: A Retrospective Cohort Study. Asian J Neurosurg 2019; 14:748-753. [PMID: 31497096 PMCID: PMC6703019 DOI: 10.4103/ajns.ajns_32_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: In 2015, a protocol to prevent rebleeding was implemented to improve the outcome of patients with ruptured intracranial aneurysm. We performed a single-center retrospective analysis to compare the outcomes of pre/post using protocol. Methodology: Over a 3-year period, 208 patients with ruptured cerebral aneurysm were treated at our institution. The protocol for preventing rebleeding was initiated in 2015. We compared the two cohorts between the group of patients before initiating the protocol (n = 104) and after initiating the protocol (n = 104). We analyzed the protocol for preventing rebleeding which consisted of absolute bed rest, adequate pain control, avoiding stimuli (R), keeping euvolemia (E), preoperative systolic blood pressure <160 mmHg and within 140–180 mmHg after definite treatment (S), a short course (<72 h) of intravenous transaminic acid, and aneurysm treatment as early as possible (T). Outcomes are presented as in-hospital rebleeding, delayed cerebral ischemia (DCI), and proportion of unfavorable outcomes (score of 4–6 on a modified Rankin scale at 6 and 12 months). Results: Postprotocol, there was a reduction in the incidence of in-hospital rebleeding from 6.7% to 2.8% (P = 0.20, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.10–1.63) and in the proportion of patients who presented with good WFNS grades (1–3) with unfavorable clinical outcomes at 12 months from 27.0% to 12.8% (P = 0.03, OR = 0.40, 95% CI = 0.17–0.95). The DCI experienced a significant reduction from 44.2% to 7.7% (P < 0.001, OR = 0.10, 95% CI = 0.04–0.23), and their 180-day mortality rate in good WFNS grades patients decreased from 16.3% to 8.8% (hazard ratio 0.80, 95% CI = 0.28–2.28). Conclusion: Ruptured cerebral aneurysm patients benefit from this protocol due to its ability to reduce the incidence of DCI and reduce unfavorable outcome on good WFNS grade patients.
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Affiliation(s)
- Pichayen Duangthongphon
- Department of Surgery, The Center of Excellence of Neurovascular Intervention and Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bunika Souwong
- Department of Surgery, The Center of Excellence of Neurovascular Intervention and Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Waranon Munkong
- Department of Radiology, The Center of Excellence of Neurovascular Intervention and Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Amnat Kitkhuandee
- Department of Surgery, The Center of Excellence of Neurovascular Intervention and Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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The path from ictus to Neurosurgery: chronology and transport logistics of patients with aneurysmal subarachnoid haemorrhage in the South-Eastern Norway Health Region. Acta Neurochir (Wien) 2019; 161:1497-1506. [PMID: 31197472 DOI: 10.1007/s00701-019-03971-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/04/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Guidelines state that patients with aneurysmal subarachnoid haemorrhage (aSAH) require neurosurgical treatment as early as possible. Little is known about the time frame of transport from the ictus scene to Neurosurgery in large, partially remote catchment areas. We therefore analysed the chronology and transport logistics of aSAH patients in the South-Eastern Norway Health Region and related them to the frequency of aneurysm rebleed and 1-year mortality. METHODS Retrospective analysis of aSAH patients bleeding within our region admitted to Neurosurgery during a 5-year period. Date, time and site of ictus and arrival at Neurosurgery, distance and mode of transport and admission were obtained from our institutional quality register and the emergency medical communication centre log. We scored the patients' clinical condition, rebleeds and 1-year mortality. RESULTS Five hundred forty-four patients were included. Median time from ictus to arrival Neurosurgery was 4.5 h. Transport by road ambulance was most common at distances between the ictus scene and Neurosurgery below 50 km, whereas airborne transport became increasingly more common at larger distances. Direct admissions, frequency of intubation and airborne transport to Neurosurgery increased with the severity of haemorrhage, leading to shorter transport times. The risk of rebleed was 0.8%/hour of transport. The rebleed rate was independent of distances travelled, but increased with the severity of aSAH, reaching up to 6.54%/hour in poor-grade patients. Distance and time of transport had no impact on 1-year mortality, whereas poor-grade aSAH and rebleed were strong predictors of mortality. CONCLUSIONS Poor-grade aSAH patients have a high risk of rebleed independent of the distance between the ictus scene and Neurosurgery. As rebleeding triples 1-year mortality, patients with Glasgow Coma Score < 9 with suspected aSAH should be admitted directly to Neurosurgery without delay after best possible cardiovascular and airway optimisation on site by competent personnel.
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Postoperative Management in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Artifact Reduction in the Diagnosis of Vasospasm in Computed Tomographic Perfusion: Potential of Iterative Metal Artifact Reduction. J Comput Assist Tomogr 2019; 43:553-558. [PMID: 31162229 DOI: 10.1097/rct.0000000000000879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study aimed to analyze the possibility of artifact reduction using a new iterative metal artifact reduction algorithm (iMAR) in the diagnosis of perfusion deficits due to vasospasms and to evaluate its clinical relevance. METHODS Sixty-one volume perfusion computed tomographies of 24 patients after coiling or aneurysm clipping were reconstructed using standard-filtered back-projection and iMAR retrospectively. The degree of artifacts was evaluated as well as the size of the nonevaluable area. Diagnostic performance was evaluated compared with digital subtraction angiography. RESULTS Artifacts were present in 39 of 61 volume perfusion computed tomography examinations. Image quality (score, 1.0 vs 1.6; P < 0.01) was higher and the size of the signal loss was reduced significantly by iMAR (intracranial metal artifacts, 887 mm vs 359 mm [P < 0.01]; cranial bolt, 3008 mm vs 837 mm [P < 0.01]). Digital subtraction angiography confirmed vasospasms in 11 (92%) of 12 patients. CONCLUSION The iMAR yields higher image quality by reducing artifacts compared with filtered back-projection.
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He Q, Zhou Y, Liu C, Zhang X, Huang N, Wang F, Liu G, Cheng Y, Xie Z. Thromboelastography with Platelet Mapping Detects Platelet Dysfunction in Patients with Aneurysmal Subarachnoid Hemorrhage with Rebleeding. Neuropsychiatr Dis Treat 2019; 15:3443-3451. [PMID: 31908459 PMCID: PMC6924584 DOI: 10.2147/ndt.s229284] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) has high rates of disability and mortality, and aneurysm rebleeding is associated with poor functional outcomes. Thrombelastography with platelet mapping (TEG-PM) measures platelet function; however, it has not yet been researched in aSAH. We aimed to use TEG-PM to detect changes in platelet function in patients with aSAH and the difference in patients with and without rebleeding. METHODS We retrospectively included patients with aSAH who underwent a TEG-PM test on admission. Rebleeding was diagnosed according to clinical and imaging data. TEG-PM data of patients with unruptured intracranial aneurysms (UIA) were also obtained as controls. Univariate and multivariate logistic regression models were performed to investigate the relationship between the platelet function and rebleeding. RESULTS A total of 245 aSAH patients and 32 UIA patients were included in our study. Compared with controls, patients with aSAH demonstrated higher arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition of platelet function (P<0.05). Among them, 27 patients with Hunt-Hess grade IV or V were classified as the severe SAH group. There was a significant correlation between the severe SAH group and the degree of pathway inhibition (P<0.05). Furthermore, AA (Spearman's r=0.264, P<0.001) and ADP (Spearman's r=0.183, P=0.004) inhibition were elevated in Hunt-Hess grade-dependent manners. The AA (Spearman's r=0.169, P=0.008) and ADP (Spearman's r=0.233, P<0.001) inhibition were also significantly correlated with Fisher grade. Thirty-five patients (14.3%) suffered rebleeding. Rebleeding was significantly correlated with systolic blood pressure (P=0.011), diastolic blood pressure (P=0.008), Hunt-Hess grade (P=0.034), Fisher grade (P=0.015), AA inhibition (P<0.001), and ADP inhibition (P<0.001). Multivariate logistic regression analysis model revealed that both AA (P=0.037) and ADP inhibition (P=0.008) were independent determinants for rebleeding. CONCLUSION TEG-PM may assess platelet dysfunction in patients with aSAH, and the diminished platelet response to ADP and AA may be associated with rebleeding. These findings deserve further investigation.
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Affiliation(s)
- Qiuguang He
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - You Zhou
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Chang Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xiang Zhang
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Ning Huang
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Feng Wang
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Guodong Liu
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yuan Cheng
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Zongyi Xie
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Darkwah Oppong M, Gümüs M, Pierscianek D, Herten A, Kneist A, Wrede K, Barthel L, Forsting M, Sure U, Jabbarli R. Aneurysm rebleeding before therapy: a predictable disaster? J Neurosurg 2018; 131:1473-1480. [PMID: 30544356 DOI: 10.3171/2018.7.jns181119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current guidelines for subarachnoid hemorrhage (SAH) include early aneurysm treatment within 72 hours after ictus. However, aneurysm rebleeding remains a crucial complication of SAH. The aim of this study was to identify independent predictors allowing early stratification of SAH patients for rebleeding risk. METHODS All patients admitted to the authors' institution with ruptured aneurysms during a 14-year period were eligible for this retrospective study. Demographic and radiographic parameters, aneurysm characteristics, medical history, and medications as well as baseline parameters at admission (blood pressure and laboratory parameters) were evaluated in univariate and multivariate analyses. A novel risk score was created using independent risk factors. RESULTS Data from 984 cases could be included into the final analysis. Aneurysm rebleeding occurred in 58 cases (5.9%), and in 48 of these cases (82.8%) rerupture occurred within 24 hours after SAH. Of over 30 tested associations, preexisting arterial hypertension (p = 0.02; adjusted odds ratio [aOR] 2.56, 1 score point), aneurysm location at the basilar artery (p = 0.001, aOR 4.5, 2 score points), sac size ≥ 9 mm (p = 0.04, aOR 1.9, 1 score point), presence of intracerebral hemorrhage (p = 0.001, aOR 4.29, 2 score points), and acute hydrocephalus (p < 0.001, aOR 6.27, 3 score points) independently predicted aneurysm rebleeding. A score built upon these parameters (0-9 points) showed a good diagnostic accuracy (p < 0.001, area under the curve 0.780) for rebleeding prediction. CONCLUSIONS Certain patient-, aneurysm-, and SAH-specific parameters can reliably predict aneurysm rerupture. A score developed according to these parameters might help to identify individuals that would profit from immediate aneurysm occlusion.
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Affiliation(s)
| | | | | | | | | | | | | | - Michael Forsting
- 2Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
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Affiliation(s)
- Chih-Wen Yang
- Department of Neurology, National Yang-Ming University Hospital, Ilan, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jong-Ling Fuh
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
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