Reduced Quality of Life in Patients with Pituitary Dysfunction After Aneurysmal Subarachnoid Hemorrhage: A Prospective Longitudinal Study

Automatic differentiation of ruptured and unruptured intracranial aneurysms on computed tomography angiography based on deep learning and radiomics

OBJECTIVES

Rupture of intracranial aneurysm is very dangerous, often leading to death and disability. In this study, deep learning and radiomics techniques were used to automatically detect and differentiate ruptured and unruptured intracranial aneurysms.

MATERIALS AND METHODS

363 ruptured aneurysms and 535 unruptured aneurysms from Hospital 1 were included in the training set. 63 ruptured aneurysms and 190 unruptured aneurysms from Hospital 2 were used for independent external testing. Aneurysm detection, segmentation and morphological features extraction were automatically performed with a 3-dimensional convolutional neural network (CNN). Radiomic features were additionally computed via pyradiomics package. After dimensionality reduction, three classification models including support vector machines (SVM), random forests (RF), and multi-layer perceptron (MLP) were established and evaluated via area under the curve (AUC) of receiver operating characteristics. Delong tests were used for the comparison of different models.

RESULTS

The 3-dimensional CNN automatically detected, segmented aneurysms and calculated 21 morphological features for each aneurysm. The pyradiomics provided 14 radiomics features. After dimensionality reduction, 13 features were found associated with aneurysm rupture. The AUCs of SVM, RF and MLP on the training dataset and external testing dataset were 0.86, 0.85, 0.90 and 0.85, 0.88, 0.86, respectively, for the discrimination of ruptured and unruptured intracranial aneurysms. Delong tests showed that there was no significant difference among the three models.

CONCLUSIONS

In this study, three classification models were established to distinguish ruptured and unruptured aneurysms accurately. The aneurysms segmentation and morphological measurements were performed automatically, which greatly improved the clinical efficiency.

CLINICAL RELEVANCE STATEMENT

Our fully automatic models could rapidly process the CTA data and evaluate the status of aneurysms in one minute.

Prevalence of pituitary dysfunction after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

BACKGROUND

Pituitary dysfunction (PD) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). The prevalence of PD varies widely at a global level and no recent meta-analysis is available. Therefore, the aim of our systematic review and meta-analysis was to summarize the updated estimates of worldwide prevalence of PD after aSAH.

METHODS

Scopus, Embase, Web of Science, and PubMed databases were used to comprehensively search the appropriate literature and a random-effects meta-analysis on the results of the available studies was performed. The heterogeneity in the prevalence estimates was evaluated by subgroup analysis in terms of types of PD, and acute and chronic phases of aSAH. The onset of PD within 6 months after aSAH was considered as acute, while that after 6 months was considered as chronic.

RESULTS

Twenty-seven studies with 1848 patients were included in this analysis. The pooled prevalence of PD in the acute phase was 49.6% (95% CI, 32.4-66.8%), and 30.4% (95% CI, 21.4-39.4%) in the chronic phase. Among the hormonal deficiencies, growth hormone dysfunction was the most prevalent in the acute phase, being 36.0% (95% CI, 21.0-51.0%), while hypoadrenalism was the most prevalent in the chronic phase, being 21.0% (95% CI, 12.0-29.0%). Among the six World Health Organization regions, the South-East Asia Region has the highest prevalence of PD in the acute phase (81.0%, 95%CI, 77.0-86.0%, P < 0.001), while the European Region had the highest prevalence of PD in the chronic phase (33.0%, 95%CI, 24.0-43.0%, P < 0.001). Moreover, single pituitary hormonal dysfunction occurred more frequently than the multiple one, regardless of acute or chronic phase.

CONCLUSIONS

Almost half (49.6%) of the included patients with aSAH developed PD complication in the acute phase, while 30.4% of the patients developed them in the chronic phase. Although prevalence varies globally, the high healthcare burden, morbidity and mortality require greater awareness among clinicians.

Copeptin and insulin-like growth factor-1 predict long-term outcomes after aneurysmal subarachnoid hemorrhage: A large prospective cohort study

OBJECTIVE

The predictive roles of copeptin and insulin-like growth factor-1 (IGF-1) in aneurysmal subarachnoid hemorrhage (aSAH) remain controversial. We aimed to define the relationship between copeptin and IGF-1 levels and functional outcome as well as quality of life (QoL) after aSAH.

METHODS

Patients with aSAH were prospectively enrolled in a tertiary university hospital. Controls were sex- and age-matched healthy subjects. Plasma concentrations of copeptin and IGF-1 were measured on admission. Demographics and clinical, radiological and laboratory characteristics of the patients were collected. Favorable functional outcome was defined as modified Rankins≤2, and QoL was evaluated by the 36-Item Short Form Health Survey (SF-36) 1 year after aSAH. Uni- and multivariable analyses were performed.

RESULTS

One hundred eighteen patients were eligible, with 122 healthy controls were included in this study. Plasma copeptin levels were significantly higher and plasma IGF-1 was lower in patients than in controls. Both copeptin (adjusted HR 4.143 [1.120-15.328], p = 0.033) and IGF-1 levels (adjusted HR 0.089 [0.013-0.602], p = 0.013) were positively associated with 1-year mortality, while only single copeptin and IGF-1 concentrations were independent predictors of poor functional outcome and QoL, respectively.

CONCLUSIONS

Plasma copeptin and IGF-1 levels are abnormal in patients with acute aSAH, and this may reliably predict long-term mortality, functional outcome and QoL.

Subarachnoid Hemorrhage is Followed by Pituitary Gland Volume Loss: A Volumetric MRI Observational Study

Background

Subarachnoid hemorrhage (SAH) is a devastating disease associated with high mortality and morbidity. Besides neurological sequelae, neuropsychological deficits largely contribute to patients’ long-term quality of life. Little is known about the pituitary gland volume (PGV) after SAH compared to healthy referents and the association of PGV with long-term outcome including cognitive function.

Methods

Sixty consecutive non-traumatic SAH patients admitted to the neurological intensive care unit between 2010 and 2014 were enrolled. 3-Tesla magnetic resonance imagining was performed at baseline (16 days) and 12 months after SAH to measure PGV semi-automatically using the software iPlan Net 3.5.0. PGV was compared to age and sex matched healthy referents. The difference between baseline and 1-year-PGV was classified as increase (> 20 mm³ PGV increase), stable (± 20 mm³), or decrease (> 20 mm³ PGV decrease). In addition, total intracerebral volume was calculated. Neuropsychological testing was applied in 43 SAH patients at 1-year follow up encompassing several domains (executive, attention, memory) and self-assessment (questionnaire for self-perceived deficits in attention [German: FEDA]) of distractibility in mental processes, fatigue and decrease in motivation. Multivariable regression with multivariable generalized linear models was used for comparison of PGVs and for subgroup analysis to evaluate a potential association between PGV and neuropsychological outcome.

Results

Patients were 53 years old (IQR = 44–63) and presented with a median Hunt&Hess grade of 2 (IQR = 1–3). SAH patients had a significantly lower PGV both at baseline (360 ± 19 mm³, p < 0.001) and 1 year (367 ± 18 mm³p < 0.001) as compared to matched referents (mean 505 ± 18 mm³). PGV decreased by 75 ± 8 mm³ in 28 patients, increased by 120 ± 22 mm³ in 22 patients and remained stable in 10 patients at 1-year follow-up. PGV in patients with PGV increase at 12 months was not different to healthy referents (p = 0.062). Low baseline PGV was associated with impaired executive functions at 1 year (adjOR = 8.81, 95%-CI = 1.46–53.10, p = 0.018) and PGV decrease within 1 year was associated with self-perceived worse motivation (FEDA; Wald-statistic = 6.6, df = 1, p = 0.010).

Conclusions

Our data indicate significantly lower PGVs following SAH. The association of sustained PGV decrease with impaired neuropsychological long-term outcome warrants further investigations including neuroendocrine hormone measurements.

Depression after Subarachnoid Hemorrhage: A Systematic Review

Background and Purpose

Depression is common and debilitating illness accompanying many neurological disorders including non-traumatic subarachnoid hemorrhage (SAH). The aim of this systematic review was to identify and critically appraise all published studies that have reported the frequency, severity and time course of depression after SAH, the factors associated with its development and the impact of depression on patients’ quality of life after SAH.

Methods

The PubMed database was searched for studies published in English that recruited at least 40 patients (>18 years old) after SAH who were also diagnosed with depression.

Results

Altogether 55 studies covering 6,327 patients met study entry criteria. The frequency of depression ranged from 0% to 61.7%, with a weighted proportion of 28.1%. Depression remained common even several years after the index SAH. Depression after SAH was associated with female sex, premorbid depression, anxiety, substance use disorders or any psychiatric disorders, and coping styles. Comorbid cognitive impairment, fatigue, and physical disability also increased the risk of depression. Aneurysmal SAH and infarction may be related to depression as well. Depression reduces the quality of life and life satisfaction in patients after SAH.

Conclusions

Depression is common after SAH and seems to persist. Further research is needed to clarify its time course and identify the neuroendocrine and neurochemical factors and brain circuits associated with the development of post-SAH depression. Randomized controlled treatment trials targeting SAH-related depression are warranted.

Neuroendocrine changes after aneurysmal subarachnoid haemorrhage

INTRODUCTION

The prevalence of pituitary dysfunction is high following aneurysmal subarachnoid hemorrhage (aSAH) and when occurs it may contribute to residual symptoms of aSAH such as decreased cognition and quality of life. Hypopituitarism following aSAH may have non-specific, subtle symptoms and potentially serious consequences if remained undiagnosed.

METHODS

We reviewed the literature on epidemiology, pathophysiology, diagnostic methods and management of neuroendocrine changes after aSAH as well as on the impact of pituitary dysfunction on outcome of the patient.

RESULTS

The prevalence rates of pituitary dysfunction after aSAH varies greatly across studies due to different diagnostic methods, though growth hormone deficiency is generally the most frequently reported followed by adrenocorticotropic hormone, gonadotropin and thyroid stimulating hormone deficiencies. Pituitary deficiency tends to improve over time after aSAH but new onset deficiencies in chronic phase may also occur. There are no clinical parameters to predict the presence of hypopituitarism after aSAH. Age of the patient and surgical procedures are risk factors associated with development of hypopituitarism but the effect of pituitary dysfunction on outcome of the patient is not clear. Replacement of hypocortisolemia and hypothyroidism is essential but treatment of other hormonal insufficiencies should be individualized.

CONCLUSIONS

Hypopituitarism following aSAH necessitates screening despite lack of gold standard evaluation tests and cut-off values in the follow up, because missed diagnosis may lead to untoward consequences.

The prevalence of growth hormone deficiency in survivors of subarachnoid haemorrhage: results from a large single centre study

OBJECTIVE

The variation in reported prevalence of growth hormone deficiency (GHD) post subarachnoid haemorrhage (SAH) is mainly due to methodological heterogeneity. We report on the prevalence of GHD in a large cohort of patients following SAH, when dynamic and confirmatory pituitary hormone testing methods are systematically employed.

DESIGN

In this cross-sectional study, pituitary function was assessed in 100 patients following SAH. Baseline pituitary hormonal profile measurement and glucagon stimulation testing (GST) was carried out in all patients. Isolated GHD was confirmed with an Arginine stimulation test and ACTH deficiency was confirmed with a short synacthen test.

RESULTS

The prevalence of hypopituitarism in our cohort was 19% and the prevalence of GHD was 14%. There was no association between GHD and the clinical or radiological severity of SAH at presentation, treatment modality, age, or occurrence of vasospasm. There were statistically significant differences in terms of Glasgow Outcome Scale (GOS; p = 0.03) between patients diagnosed with GHD and those without. Significant inverse correlations between GH peak on GST with body mass index (BMI) and waist hip ratio (WHR) was also noted (p < 0.0001 and p < 0.0001 respectively).

CONCLUSION

Using the current testing protocol, the prevalence of GHD detected in our cohort was 14%. It is unclear if the BMI and WHR difference observed is truly due to GHD or confounded by the endocrine tests used in this protocol. There is possibly an association between the development of GHD and worse GOS score. Routine endocrine screening of all SAH survivors with dynamic tests is time consuming and may subject many patients to unnecessary side-effects. Furthermore the degree of clinical benefit derived from growth hormone replacement in this patient group, remains unclear. Increased understanding of the most appropriate testing methodology in this patient group and more importantly which SAH survivors would derive most benefit from GHD screening is required.

[Depression and depression-related disorders after a subarachnoid hemorrhage]

Psychiatric disorders often develop after subarachnoid hemorrhage (SAH); the most frequent of them are depression and depression-related disorders (anxiety, apathy, pathological fatigue, posttraumatic stress disorder, etc.). Both biological and psychological mechanisms may underlie the development of these disorders. Depression and depression-related disorders decrease patients' quality of life and prevent the full recovery after SAH. Identification and correction of these disorders should take a prominent place in the rehabilitation of post-SAH patients. More research is needed in this area.

High Prolactin Level as a Predictor of Vasospasm in Aneurysmal Subarachnoidal Hemorrhage

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a destructive syndrome with a mortality rate of 50%. Recent studies have also suggested a high pervasiveness of hypothalamic-pituitary insufficiency in up to 45% of patients after aSAH. Prolactin has been associated with the pathogenesis of hypertensive irregularities that are linked to pregnancy.

Material/Methods

We identified a group of 141 patients with spontaneous SAH due to a ruptured cerebral aneurysm; these patients were operated on at our institution’s Neurosurgery and Interventional Radiology Department between 2011 and June 2015. All of the data were obtained retrospectively from medical records.

Results

The hormonal abnormalities observed in the initial 24 h after ictus in subjects with subarachnoid SAH were caused by stressful stimulation aggravated by intracranial bleeding.

Conclusions

The elevated prolactin levels that occur in patients with aSAH can be used in conjunction with other auxiliary factors that we believe may be beneficial to vasospasm.