Anticoagulation Therapy in Patients Suffering from Aneurysmal Subarachnoid Hemorrhage: Influence on Functional Outcome—a Single-Center Series and Multivariate Analysis

Non-Convulsive Status Epilepticus in Aneurysmal Subarachnoid Hemorrhage: A Prognostic Parameter

A non-convulsive status epilepticus (ncSE) is a potentially fatal complication for patients in neurointensive care. In patients with aneurysmal subarachnoid hemorrhage (SAH), ncSE remains scarcely investigated. In this study, we aim to investigate the frequency and influence of non-convulsive status epilepticus on outcome in patients with SAH. We retrospectively analyzed data of consecutive patients with aneurysmal subarachnoid hemorrhage and evaluated clinical, radiological, demographical and electroencephalogram (EEG) data. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months and stratified into favorable (mRS 0-2) vs. unfavorable (mRS 3-6). We identified 171 patients with SAH, who received EEG between 01/2012 and 12/2020. ncSE was diagnosed in 19 patients (3.7%), only one of whom achieved favorable outcome. The multivariate regression analysis revealed four independent predictors of unfavorable outcome: presence of ncSE (p = 0.003; OR 24.1; 95 CI% 2.9-195.3), poor-grade SAH (p < 0.001; OR 14.0; 95 CI% 8.5-23.1), age (p < 0.001; OR 2.8; 95 CI% 1.6-4.6) and the presence of DIND (p < 0.003; OR 1.9; 95 CI% 1.2-3.1) as independent predictors for unfavorable outcome. According to our study, development of ncSE in patients suffering SAH might correlate with poor prognosis. Even when medical treatment is successful and no EEG abnormalities are detected, the long-term outcome remains poor.

Clinical Presentation, Treatment, and Outcome of Nontraumatic Subarachnoid Hemorrhage in Patients with Preceding Antithrombotic Therapy

With the aging of the population, the number of people taking antithrombotic drugs is increasing. Few reports have described the clinical presentation, treatment, and outcomes of nontraumatic subarachnoid hemorrhage (SAH) in patients with preceding antithrombotic therapy. This study included 459 patients with nontraumatic SAH who had been treated between April 2009 and May 2021. Overall, 39 of the 459 patients with aneurysmal SAH were on antithrombotic therapy before ictus (8.5%). Therefore, we classified patients into two groups: Group A (n = 39), patients with preceding antithrombotic therapy and Group B (n = 420), patients without preceding antithrombotic therapy. Hunt and Kosnik (H&K) grade on admission was significantly higher in Group A than in Group B (p = 0.02). Patients in Group A more frequently received endovascular treatment. The rate of endovascular therapy for symptomatic vasospasm after SAH was significantly lower in Group A (2.6%) than in Group B (15.5%; p = 0.03). The outcomes at 3 months after onset were significantly poorer in Group A patients than in Group B patients (p = 0.03). Patients with preceding antithrombotic drugs tended to be at greater risk of unfavorable outcomes, but this difference was not significant in the univariate analysis. In the multivariate analysis, patient age, H&K grade ≥4, and subdural hematoma remained as risk factors for poor outcomes; however, preceding use of antithrombotic drugs was not a significant risk factor.

Association of Pericyte Loss With Microthrombosis After Subarachnoid Hemorrhage in ApoE-Deficient Mice

Background: The occurrence of microthrombosis contributes to not only delayed cerebral ischemia (DCI), but also early brain injury (EBI) after SAH. However, the underlying mechanism is not completely investigated. In the current study, we explored the underlying mechanism of microthrombosis in EBI stage after SAH in ApoE-deficient mice.

Methods: Experimental SAH was established by endovascular perforation in apolipoprotein E (ApoE)-deficient mice and wild type (WT) mice. Neurobehavioral, molecular biological and histopathological methods were used to assess the relationship between pericytes loss, neurobehavioral performance, and microthrombosis.

Results: We found that the number of microthrombi was significantly increased and peaked 48 h after SAH in WT mice. The increased microthrombosis was related to the decreased effective microcirculation perfusion area and EBI severity. ApoE-deficient mice showed more extensive microthrombosis than that of WT mice 48 h after SAH, which was thereby associated with greater neurobehavioral deficits. Immunohistochemical staining showed that microthrombi were predominantly located in microvessels where pericytes coverage was absent. Mechanistically, ApoE deficiency caused more extensive CypA-NF-κB-MMP-9 pathway activation than that observed in WT mice, which thereby led to more degradation of N-cadherin, and subsequently more pericytes loss. Thereafter, the major adhesion molecule that promoting microthrombi formation in microvessels, P-selectin, was considerably increased in WT mice and increased to a greater extent in the ApoE-deficient mice.

Conclusion: Taken together, these data suggest that pericytes loss is associated with EBI after SAH through promoting microthrombosis. Therapies that target ApoE to reduce microthrombosis may be a promising strategy for SAH treatment.

Does the discontinuation time of antiplatelet or anticoagulation treatment affect hemorrhagic complications in patients undergoing craniotomy for neurovascular lesions?

BACKGROUND

The number of patients treated with platelet inhibitors (PI) and/or anticoagulants (AC) in neurosurgery is increasing. The aim of this study was to analyse the effect of PI/AC discontinuation time on hemorrhagic events after craniotomy for neurovascular pathologies.

METHODS

The 30-day postoperative bleeding rates were retrospectively compared between short (≤5 days) and long (>5 days) discontinuation time of PI/AC before and after surgery. Kaplan-Meier survival analysis comparing time to postoperative bleeding and the effect of PI/AC discontinuation time on bleeding rates were analysed. Potential risk factors for postoperative bleeding were further analysed in uni- and multivariate analysis.

RESULTS

Out of 215 consecutive patients undergoing craniotomy for neurovascular lesions between January 2009 and April 2019, 23.3% were treated with PI/AC. Of these 36% (n = 18) and 20.8% (n = 10) were included in the short pre- and postoperative discontinuation group, respectively. Bleeding rates were comparable between the pre- and postoperative short and long discontinuation groups (preoperative 11.1% vs 10%, p = .659; postoperative 0% vs 13.2%, p = .566). In-hospital mortality rates and time to bleed of the groups were comparable as well. Similarly, the rate for thromboembolic events was not significantly affected by the pre- or postoperative discontinuation time of PI/AC. After multivariate analysis preoperative bleeding of the lesion was significantly associated with postoperative bleeding.

CONCLUSIONS

Patients with short discontinuation time of PI/AC treatment undergoing craniotomy for the treatment of neurovascular lesions do not appear to have increased rates of postoperative bleeding.

MR-Imaging and Histopathological Diagnostic Work-Up of Patients with Spontaneous Lobar Intracerebral Hemorrhage: Results of an Institutional Prospective Registry Study

Intracerebral hemorrhage (ICH) is a frequently disabling or fatal disease. The localization of ICH often allows an etiological association. However, in atypical/lobar ICH, the cause of bleeding is less obvious. Therefore, we present prospective histopathological and radiological studies which were conducted within the diagnostic workup to identify causes for lobar ICH other than hypertension. From 2016 to 2018, 198 patients with spontaneous, non-traumatic ICH requiring neurosurgical monitoring were enrolled in an institutional prospective patient registry. Patients with deep-seated ICH and/or hemorrhagically transformed cerebral infarcts were excluded from further analysis. Data to evaluate the source of bleeding based on histopathological and/or radiological workup were prospectively evaluated and analyzed. After applying the inclusion criteria and excluding patients with incomplete diagnostic workup, a total of 52 consecutive patients with lobar ICH were further analyzed. Macrovascular disease was detected in 14 patients with lobar ICH (27%). In 11 patients, diagnostic workup identified cerebral amyloid angiopathy-related ICH (21%). In addition, five patients with tumor-related ICH (10%) and six patients with ICH based on infectious pathologies (11%) were identified. In four patients, the cause of bleeding remained unknown despite extensive diagnostic workup (8%). The present prospective registry study demonstrates a higher probability to identify a cause of bleeding other than hypertension in patients with lobar ICH. Therefore, a thorough diagnostic work-up in patients with ICH is essential to accelerate treatment and further improve outcome or prevent rebleeding.

Initial inflammatory response is an independent predictor of unfavorable outcome in patients with good-grade aneurysmal subarachnoid hemorrhage

INTRODUCTION

Purpose of the present study was to determine if routine biochemical markers of acute phase response are associated with unfavorable outcome in patients with good-grade aneurysmal SAH.

METHODS

231 patients admitted with aneurysmal SAH and WFNS grade I - II were included in the present study. C-reactive protein (CRP) and procalcitonin (PCT) were measured within 24 h of admission. Outcome was assessed according to the modified Rankin Scale (mRS) after 6 months and stratified into favorable (mRS 0-2) vs. unfavorable (mRS 3-6).

RESULTS

The multivariate regression analysis revealed "elevated baseline CRP" (p = .001, OR 3.2, 95% CI 1.6-6.6), "elevated baseline PCT" (p = .004, OR 26.0, 95% CI 2.9-235.5), "male gender" (p = .02, OR 2.3, 95% CI 1.1-4.8), and "age ≥ 65 years" (p = .009, OR 2.7, 95% CI 1.3-5.8) as a model for the prediction of unfavorable outcome in patients with good-grade SAH.

CONCLUSION

An initial inflammatory response could be a possible explanation for poor outcome in good-grade SAH patients. These findings might help to identify a subgroup of good grade SAH patients who are at greater risk for unfavorable outcome early during treatment course/at baseline, and who could benefit most from potential anti-inflammatory therapy.