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Julian N, Gaugain S, Labeyrie MA, Barthélémy R, Froelich S, Houdart E, Mebazaa A, Chousterman BG. Systemic tolerance of intravenous milrinone administration for cerebral vasospasm secondary to non-traumatic subarachnoid hemorrhage. J Crit Care 2024; 82:154807. [PMID: 38579430 DOI: 10.1016/j.jcrc.2024.154807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 03/18/2024] [Accepted: 03/27/2024] [Indexed: 04/07/2024]
Abstract
PURPOSE Delayed cerebral ischemia (DCI) is a severe subarachnoid hemorrhage (SAH) complication, closely related to cerebral vasospasm (CVS). CVS treatment frequently comprises intravenous milrinone, an inotropic and vasodilatory drug. Our objective is to describe milrinone's hemodynamic, respiratory and renal effects when administrated as treatment for CVS. METHODS Retrospective single-center observational study of patients receiving intravenous milrinone for CVS with systemic hemodynamics, oxygenation, renal disorders monitoring. We described these parameters' evolution before and after milrinone initiation (day - 1, baseline, day 1 and day 2), studied treatment cessation causes and assessed neurological outcome at 3-6 months. RESULTS Ninety-one patients were included. Milrinone initiation led to cardiac output increase (4.5 L/min [3.4-5.2] at baseline vs 6.6 L/min [5.2-7.7] at day 2, p < 0.001), Mean Arterial Pressure decrease (101 mmHg [94-110] at baseline vs 95 mmHg [85-102] at day 2, p = 0.001) norepinephrine treatment requirement increase (32% of patients before milrinone start vs 58% at day 1, p = 0.002) and slight PaO2/FiO2 ratio deterioration (401 [333-406] at baseline vs 348 [307-357] at day 2, p = 0.016). Milrinone was interrupted in 8% of patients. 55% had a favorable outcome. CONCLUSION Intravenous milrinone for CVS treatment seems associated with significant impact on systemic hemodynamics leading sometimes to treatment discontinuation.
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Affiliation(s)
- Nathan Julian
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France.
| | - Samuel Gaugain
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
| | - Marc-Antoine Labeyrie
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Interventional Neuroradiology, Hopital Lariboisière, Paris, France
| | - Romain Barthélémy
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, University of Paris, France
| | - Emmanuel Houdart
- Department of Interventional Neuroradiology, Hopital Lariboisière, Paris, France
| | - Alexandre Mebazaa
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
| | - Benjamin G Chousterman
- Université de Paris, INSERM, U942 MASCOT, Paris F-75006, France; Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris F-75010, France
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Tawakul A, Alluqmani MM, Badawi AS, Alawfi AK, Alharbi EK, Aljohani SA, Mogharbel GH, Alahmadi HA, Khawaji ZY. Risk Factors for Cerebral Vasospasm After Subarachnoid Hemorrhage: A Systematic Review of Observational Studies. Neurocrit Care 2024:10.1007/s12028-024-02059-2. [PMID: 39048760 DOI: 10.1007/s12028-024-02059-2] [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: 01/11/2024] [Accepted: 06/25/2024] [Indexed: 07/27/2024]
Abstract
Cerebral vasospasm (CV) following subarachnoid hemorrhage (SAH) remains one of the leading causes of high mortality and poor outcomes. Understanding the risk factors associated with CV is pivotal to improving patients' outcomes. We conducted an extensive search for analytical observational studies that analyzed the correlation between various variables and the likelihood of CV development among adult patients with SAH (age ≥ 18 years). Five scholar databases were used, namely, PubMed, EBSCO, Web of Science, Science Direct, and Google Scholar. Relevant studies published between January 1st, 2016, and August 9th, 2023, were included. The Newcastle-Ottawa Scale was adopted to assess the risk of bias among included observational studies. A total of 33 studies met the inclusion criteria. Of the 24,958 patients with SAH who were identified, 6,761 patients had a subsequent CV (27.1%). Several statistically significant risk factors were reported across the literature. Younger age, female sex, smoking, alcohol intake, modified Fisher grade 3-4, higher Hunt and Hess grading, and the presence of multiple comorbidities (diabetes, hypertension, congestive heart failure, and history of stroke) were among the well-established risk factors for CV. Additionally, leukocytosis was consistently reported to be a significant predictor in multiple studies, providing compelling evidence for its association with CV. Even though single studies reported an association between CV and certain variables, further research is necessary to investigate the implications of these findings. These include arterial tortuosity, hypokalemia, potassium to glucose gradient, hypoalbuminemia, anemia, von Willebrand factor and vascular endothelial growth factor, use of desflurane, and hemodynamic stability. Overall, this systemic review provides a comprehensive summary of the current data that evaluates the potential risk factors for the development of CV after SAH. However, because of data heterogeneity, certain factors require further validation in their correlation with CV development. Larger-scale observational and clinical trials are mandatory to extensively investigate the significant predictors of CV to lay the scientific foundation for improving outcomes in susceptible patients with SAH.
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Affiliation(s)
- Abdullah Tawakul
- Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Majed Mohammedali Alluqmani
- Department of Neurology and Neuroimmunology and Neuroinflammatory, Demyelinating Disease, College of Medicine, Taibah University, Madinah, Saudi Arabia
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Becerril-Gaitan A, Nguyen T, Liu C, Mokua C, Gusdon AM, Brown RJ, Cochran J, Blackburn S, Chen PR, Dannenbaum M, Choi HA, Chen CJ. The Effect of Age on Cerebral Vasospasm and Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2024; 187:e1017-e1024. [PMID: 38750887 DOI: 10.1016/j.wneu.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/07/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND The association between patient age and cerebral arterial vasospasm (CVS) and delayed cerebral ischemia (DCI) risk following aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. This study aims to assess the role of age on aSAH-related complications. METHODS Single-center retrospective study comprising aSAH patients treated between January 2009 and March 2023. Age was analyzed as continuous and categorical variables (<60 yrs vs. ≥60 yrs and by decade). Outcomes of interest included radiographic CVS, DCI, cerebral infarction, in-hospital mortality, length-of-stay (LOS), ventriculoperitoneal shunt placement, and modified Rankin Scale (mRS) scores at discharge and 3-month follow-up. RESULTS Nine hundred and twenty-five aSAH patients were included. Most (n = 598; 64.6%) were <60 yrs old (46 ± 9.1 yrs). CVS likelihood was lower in the older cohort (aOR = 0.56 [0.38-0.82]). Patients ≥60 yrs had higher mortality rates (aOR = 2.24 [1.12-4.47]) and worse mRS scores at discharge (aOR = 2.66 [1.91-3.72]) and 3-month follow-up (aOR = 2.19 [1.44-3.32]). Advanced age did not have a significant effect on DCI or cerebral infarction risk. Higher in-hospital mortality was documented with increasing age (P < 0.001). A significant interaction between CVS and age for the outcome of DCI was documented, with a stronger positive effect on poor outcomes (i.e., higher odds of DCI) among patients aged <60 years compared to those aged ≥60. CONCLUSIONS There is an inverse relationship between patient age and CVS incidence following aSAH. Nonetheless, patients ≥60 yrs had comparable DCI rates, higher in-hospital mortality, and worse functional outcomes than their younger counterparts. Routine screening and reliance on radiographic CVS as primary marker for aSAH-related complications should be reconsidered, particularly in older patients.
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Affiliation(s)
- Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Tien Nguyen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Collin Liu
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Collins Mokua
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Aaron M Gusdon
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Robert J Brown
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Joseph Cochran
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Spiros Blackburn
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Peng Roc Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mark Dannenbaum
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Huimahn A Choi
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
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Yang C, Zhao Z, Yang B, Wang K, Zhu G, Miao H. Sex Differences in Outcome of Aneurysmal Subarachnoid Hemorrhage and Its Relation to Postoperative Cerebral Ischemia. Neurocrit Care 2024:10.1007/s12028-024-02028-9. [PMID: 38954369 DOI: 10.1007/s12028-024-02028-9] [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: 01/24/2024] [Accepted: 05/31/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Whether there is a sex difference in the outcome of aneurysmal subarachnoid hemorrhage (aSAH) remains controversial, and clarifying the role of women in postoperative cerebral ischemic events can help us to understand its relationship with poor prognosis. Therefore, the purpose of this study was to elucidate the relationship between the three aspects of sex differences, postoperative cerebral ischemia, and poor prognosis after aSAH. METHODS A total of 472 patients admitted within 72 h after aSAH between January 2018 and December 2022 were included. We systematically analyzed the characteristics of sex differences in aSAH and explored the relationship between delayed cerebral ischemia (DCI), surgery-related cerebral infarction (SRCI), and poor prognosis (modified Rankin Scale > 2). RESULTS Compared with women, men were in worse condition and had more intracerebral hematoma (p = 0.001) on admission, whereas women were older (p < 0.001) and had more multiple aneurysms (p = 0.002). During hospitalization, men were more likely to experience emergency intubation (p = 0.036) and tracheotomy (p = 0.013). Women achieved functional independence at discharge at a similar rate to men (p = 0.394). Among postoperative complications, the incidence of DCI (22% vs. 12%, p = 0.01) and urinary tract infection (p = 0.022) was significantly higher in women. After adjusting for age, multivariable regression analysis showed that hypertension (odds ratio [OR] 2.139, 95% confidence interval [CI] 1.027-4.457), preoperative rerupture (OR 12.240, 95% CI 1.491-100.458), pulmonary infection (OR 2.297, 95% CI 1.070-4.930), external ventricular drainage placement (OR 4.382, 95% CI 1.550-12.390), bacteremia (OR 14.943, 95% CI 1.412-158.117), SRCI (OR 8.588, 95% CI 4.092-18.023), venous thrombosis (OR 5.283, 95% CI 1.859-15.013), higher modified Fisher grades (p = 0.003), and Hunt-Hess grades (p = 0.035) were associated with poor prognosis, whereas DCI (OR 1.394, 95% CI 0.591-3.292) was not an independent risk factor for poor prognosis. The proportion of patients who fully recovered from cerebral ischemia was higher in the DCI group (p < 0.001) compared with the SRCI group, and more patients were discharged with modified Rankin Scale > 2 in the SRCI group (p = 0.005). CONCLUSIONS Women have a higher incidence of DCI, but there is no sex difference in outcomes after aSAH, and poor prognosis is associated with worse admission condition and perioperative complications. SRCI is a strong independent risk factor for poor prognosis, whereas DCI is not.
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Affiliation(s)
- Cheng Yang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Zenan Zhao
- Department of Neurosurgery, Chongqing Western Hospital, Chongqing, 400052, China
| | - Biao Yang
- Department of Neurosurgery, Dazu Hospital of Chongqing Medical University, Chongqing, 402360, China
| | - Kaishan Wang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Hongping Miao
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China.
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Shin KW, Park EB, Jo WY, Lee HC, Park HP, Oh H. Association Between High Preoperative White Blood Cell-to-Hemoglobin Ratio and Postoperative Symptomatic Cerebral Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2024:00008506-990000000-00114. [PMID: 38884151 DOI: 10.1097/ana.0000000000000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/16/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (ASAH) is a serious complication and has a strong relationship with systemic inflammatory responses. Given previously reported relationships between leukocytosis and anemia with ASAH-related cerebral vasospasm, this study examined the association between the preoperative white blood cell-to-hemoglobin ratio (WHR) and postoperative symptomatic cerebral vasospasm (SCV) in patients with ASAH. METHODS Demographic, preoperative (comorbidities, ASAH characteristics, laboratory findings), intraoperative (operation and anesthesia), and postoperative (SCV, other neurological complications, clinical course) data were retrospectively analyzed in patients with ASAH who underwent surgical or endovascular treatment of the culprit aneurysm. Patients were divided into high-WHR (n=286) and low-WHR (n=257) groups based on the optimal cutoff value of preoperative WHR (0.74), and stabilized inverse probability weighting was performed between the 2 groups. The predictive power of the WHR and other preoperative systemic inflammatory indices (neutrophil-to-albumin, neutrophil-to-lymphocyte, platelet-to-lymphocyte, platelet-to-neutrophil, platelet-to-white blood cell ratios, and systemic immune-inflammation index) for postoperative SCV was evaluated. RESULTS Postoperative SCV was more frequent in the high-WHR group than in the low-WHR group before (33.2% vs. 12.8%; P<0.001) and after (29.4% vs. 19.1%; P=0.005) inverse probability weighting. Before weighting, the predictive power for postoperative SCV was the highest for the WHR among the preoperative systematic inflammatory indices investigated (area under receiver operating characteristics curve 0.66, P<0.001). After weighting, preoperative WHR ≥0.74 was independently associated with postoperative SCV (odds ratio 1.76; P=0.006). CONCLUSIONS High preoperative WHR was an independent predictor of postoperative SCV in patients with ASAH.
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Affiliation(s)
- Kyung Won Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Bender M, Stein M, Tajmiri-Gondai S, Haferkorn K, Voigtmann H, Uhl E. Troponin I as a Predictor of Transcranial Doppler Sonography Defined Vasospasm in Intensive Care Unit Patients After Spontaneous Subarachnoid Hemorrhage. J Intensive Care Med 2024:8850666241253213. [PMID: 38839250 DOI: 10.1177/08850666241253213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
OBJECTIVE Elevation of Troponin I (TnI) in spontaneous subarachnoid hemorrhage (SAH) patients is a well-known phenomenon and associated with cardiopulmonary complications and poor outcome. The present study was conducted to investigate the association of the TnI value on admission, and the occurrence of cerebral vasospam in SAH patients. PATIENTS AND METHODS A total of 142 patients with SAH, who were admitted to the neurosurgical intensive care unit (ICU) between December 2014 and January 2021 were evaluated. Blood samples were drawn on admission to determine TnI value. Each patient's demographic, radiological and medical data on admission, the modified Ranking Scale score at discharge as well as continuous measurements of transcranial Doppler sonography were analyzed. A maximum mean flow velocity (MMFV) > 120 cm/sec was defined as any vasospasm. These were stratified into severe vasospasms, which were defined as at least two measurements of MMFVs > 200 cm/sec or an increase of MMFV > 50 cm/sec/24 h over two consecutive days or a new neurological deterioration and mild vasospasm defined as MMFVs > 120 cm/sec in absence of severe vasospasm criteria. The total study population was dichotomized into patients with an initially elevated TnI (>0.05 µg/L) and without elevated TnI (≤0.05 μg/L). RESULTS A total of 52 patients (36.6%) had an elevated TnI level upon admission, which was significantly associated with lower GCS score (p < 0.001), higher WFNS score (p < 0.001) and higher Fisher grade (p = 0.01) on admission. In this context a higher rate of ischemic brain lesions (p = 0.02), a higher modified Rankin Scale score (p > 0.001) and increased mortality (p = 0.02) at discharge were observed in this group. In addition, TnI was identified as an independent predictor for the occurrence of any vasospasm and severe vasospasm. CONCLUSION An initially elevated TnI level is an independent predictor for the occurrence of any and severe vasospasm in patients with SAH.
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Affiliation(s)
- Michael Bender
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - M Stein
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - S Tajmiri-Gondai
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - K Haferkorn
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - Hans Voigtmann
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - E Uhl
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
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Mistry AM, Naidugari J, Feldman MJ, Magarik JA, Ding D, Abecassis IJ, Semler MW, Rice TW. Impact of fludrocortisone on the outcomes of subarachnoid hemorrhage patients: A retrospective analysis. J Stroke Cerebrovasc Dis 2024; 33:107643. [PMID: 38387759 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/05/2024] [Accepted: 02/18/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Whether the use of fludrocortisone affects outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS We conducted a retrospective analysis of 78 consecutive patients with a ruptured aSAH at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days. The primary outcome was adjusted for age, hypertension, aSAH grade, and time from aSAH onset to aneurysm treatment. Secondary outcomes were neurologic and cardiopulmonary dysfunction events. RESULTS Among 78 patients at a single center, the median age was 58 years [IQR, 49 to 64.5]; 64 % were female, and 41 (53 %) received fludrocortisone. The adjusted common odds ratio, aOR, of a proportional odds regression model of fludrocortisone use with mRS was 0.33 (95 % CI, 0.14-0.80; P = 0.02), with values <1.0 favoring fludrocortisone. Organ-specific dysfunction events were not statistically different: delayed cerebral ischemia (22 % vs. 39 %, P = 0.16); cardiac dysfunction (0 % vs. 11 %; P = 0.10); and pulmonary edema (15 % vs. 8 %; P = 0.59). CONCLUSIONS The risk of disability or death at 90 days was lower with the use of fludrocortisone in aSAH patients.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Michael J Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jordan A Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Isaac J Abecassis
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Ma K, Bebawy JF. Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature. Anesth Analg 2024; 138:992-1002. [PMID: 38109853 DOI: 10.1213/ane.0000000000006772] [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: 12/20/2023]
Abstract
Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.
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Affiliation(s)
- Kan Ma
- From the Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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9
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Fernández-Pérez I, Jiménez-Balado J, Macias-Gómez A, Suárez-Pérez A, Vallverdú-Prats M, Pérez-Giraldo A, Viles-García M, Peris-Subiza J, Vidal-Notari S, Giralt-Steinhauer E, Guisado-Alonso D, Esteller M, Rodriguez-Campello A, Jiménez-Conde J, Ois A, Cuadrado-Godia E. Blood DNA Methylation Analysis Reveals a Distinctive Epigenetic Signature of Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Transl Stroke Res 2024:10.1007/s12975-024-01252-x. [PMID: 38649590 DOI: 10.1007/s12975-024-01252-x] [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: 02/27/2024] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 04/25/2024]
Abstract
Vasospasm is a potentially preventable cause of poor prognosis in patients with aneurysmal subarachnoid hemorrhage (aSAH). Epigenetics might provide insight on its molecular mechanisms. We aimed to analyze the association between differential DNA methylation (DNAm) and development of vasospasm. We conducted an epigenome-wide association study in 282 patients with aSAH admitted to our hospital. DNAm was assessed with the EPIC Illumina chip (> 850 K CpG sites) in whole-blood samples collected at hospital admission. We identified differentially methylated positions (DMPs) at the CpG level using Cox regression models adjusted for potential confounders, and then we used the DMP results to find differentially methylated regions (DMRs) and enriched biological pathways. A total of 145 patients (51%) experienced vasospasm. In the DMP analysis, we identified 31 CpGs associated with vasospasm at p-value < 10-5. One of them (cg26189827) was significant at the genome-wide level (p-value < 10-8), being hypermethylated in patients with vasospasm and annotated to SUGCT gene, mainly expressed in arteries. Region analysis revealed 13 DMRs, some of them annotated to interesting genes such as POU5F1, HLA-DPA1, RUFY1, and CYP1A1. Functional enrichment analysis showed the involvement of biological processes related to immunity, inflammatory response, oxidative stress, endothelial nitric oxide, and apoptosis. Our findings show, for the first time, a distinctive epigenetic signature of vasospasm in aSAH, establishing novel links with essential biological pathways, including inflammation, immune responses, and oxidative stress. Although further validation is required, our results provide a foundation for future research into the complex pathophysiology of vasospasm.
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Affiliation(s)
- Isabel Fernández-Pérez
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
| | - Joan Jiménez-Balado
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain.
| | - Adrià Macias-Gómez
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
| | - Antoni Suárez-Pérez
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
| | - Marta Vallverdú-Prats
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
| | | | - Marc Viles-García
- Neuroradiology Department, Hospital del Mar, Barcelona, Catalunya, Spain
| | | | | | - Eva Giralt-Steinhauer
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
| | - Daniel Guisado-Alonso
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
| | - Manel Esteller
- Cancer Epigenetics Group, Research Institute Against Leukemia Josep Carreras, Badalona, Catalunya, Spain
- Physiological Sciences Department, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Ana Rodriguez-Campello
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
| | - Jordi Jiménez-Conde
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
| | - Angel Ois
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
| | - Elisa Cuadrado-Godia
- Neurology Department, Hospital del Mar, Barcelona, Catalunya, Spain
- Neurovascular Research Group, Hospital del Mar Medical Research Institute, C/Dr. Aiguader, 88, 08003, Barcelona, Catalunya, Spain
- Pompeu Fabra University, Barcelona, Catalunya, Spain
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10
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Florez-Perdomo WA, Reyes Bello JS, García-Ballestas E, Moscote-Salazar LR, Barthélemy EJ, Janjua T, Maurya VP, Agrawal A. "Aneurysmal Subarachnoid Hemorrhage and Cocaine Consumption: A Systematic Review and Metanalysis". World Neurosurg 2024; 184:241-252.e2. [PMID: 38072159 DOI: 10.1016/j.wneu.2023.12.020] [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: 11/23/2023] [Accepted: 12/04/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND The use of cocaine can lead to a variety of neurologic complications, including cerebral vasoconstriction, ischemia, aneurysm formation, and aneurysm rupture. A previous study has shown that cocaine use is associated with an increased risk of subarachnoid hemorrhage (SAH). This study conducted a systematic review and meta-analysis of observational studies to assess the association between cocaine use and the risk of poor neurological outcomes and mortality in patients with SAH. METHODS A systematic review and meta-analysis were performed following the meta-analysis of observational studies in epidemiology (MOOSE) declaration for systematic reviews and the Cochrane Manual of Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs), nonrandomized clinical trials, and prospective and retrospective cohort studies that reported data about adults who suffered Aneurysmal Subarachnoid Hemorrhage (aSAH) after having consumed cocaine recreationally were included. Variables such as mortality, vasospasm, seizures, re-bleeding, and complications were analyzed. RESULTS After a thorough selection process, 14 studies involving 116,141 patients, of which 2227 had a history of cocaine consumption, were included in the analysis. There was a significant increase in overall unfavorable outcomes in aSAH patients with a history of cocaine use (OR 5.51 CI 95% [4.26-7.13] P = <0.0001; I2 = 78%), with higher mortality and poor neurologic outcomes. There were no significant differences in the risk of hydrocephalus, seizures, or re-bleeding. Cocaine use was found to increase the risk of vasospasm and overall complications. CONCLUSIONS This study insinuates that cocaine use is associated with worse clinical outcomes in aSAH patients. Despite the cocaine users did not exhibit a higher risk of certain complications such as hydrocephalus and seizures, they had an increased risk of vasospasm and overall complications. These findings highlight the importance of addressing the issue of cocaine consumption as a primary preventive measure to decrease the incidence of aSAH and improve patient outcomes.
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Affiliation(s)
- William Andres Florez-Perdomo
- Department of Neurocritical Care, Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia; Department of Research, European Stroke Organization (ESO), Basel, Switzerland.
| | - Juan Sebastian Reyes Bello
- Department of Neurocritical Care, Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia
| | - Ezequiel García-Ballestas
- Department of Neurocritical Care, Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia
| | | | - Ernest J Barthélemy
- Department of Neurosurgery, SUNY Downstate Health sciences University, Brooklin, New York, USA
| | - Tariq Janjua
- Department of Critical Care, Neurocritical Care Unit, Regions Hospital Saint Paul, Saint Paul, Minnessota, USA
| | - Ved Prakash Maurya
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
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11
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Tokareva B, Meyer L, Heitkamp C, Wentz R, Faizy TD, Meyer HS, Bester M, Fiehler J, Thaler C. Early and recurrent cerebral vasospasms after aneurysmal subarachnoid hemorrhage: The impact of age. Eur Stroke J 2024; 9:172-179. [PMID: 37910182 PMCID: PMC10916818 DOI: 10.1177/23969873231209819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/07/2023] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Cerebral vasospasms remain a strong predictor of poor outcome after aneurysmal SAH. The aim of this study was to describe the time course of relevant vasospasms after aneurysmal SAH and to determine the variables associated with early-onset or prolonged and recurrent vasospasms. PATIENTS AND METHODS We conducted a retrospective, single-center study of consecutive adult patients with aneurysmal SAH admitted between 2016 and 2022 at our tertiary stroke center. Relevant vasospasms, defined as vessel narrowing detected in DSA in combination with clinical deterioration or new perfusion deficit, were detected according to our in-house algorithm and eventually treated endovascularly. The primary endpoint was the diagnosis of relevant vasospasms. As secondary endpoints, the time from hemorrhage to the onset of vasospasms and the time from the first to the last endovascular intervention were measured. RESULTS Of 368 patients with aneurysmal SAH, 135 (41.0%) developed relevant vasospasms. The median time between ictus and detection of vasospasms was 8 days (IQR: 6-10). Patients with early-onset vasospasms were significantly younger (mean 52.7 ± 11.2 years vs 58.7 ± 11.5 years, p = 0.003) and presented more frequently vasospasm-related infarctions at discharge (58.8% vs 38.7%, p = 0.03). In 74 patients (54.8%), recurrent relevant vasospasms were observed despite endovascular treatment. Younger age and early onset were significantly associated with longer duration of relevant vasospasms (both p < 0.05). DISCUSSION AND CONCLUSION Younger age was associated with early-onset and longer duration of relevant vasospasms in this study. More frequent clinical and diagnostic follow-up should be considered in this subgroup of patients that are at risk for poor outcomes.
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Affiliation(s)
- Bogdana Tokareva
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rabea Wentz
- Department of Diagnostic and Interventional Radiology, Katholisches Marienkrankenhaus, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno S Meyer
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Zhou Y, Qian D, Zhou Z, Li B, Ma Y, Chai E. A nomogram for predicting the risk of cerebral vasospasm after neurosurgical clipping in patients with aneurysmal subarachnoid hemorrhage. Front Neurol 2024; 15:1300930. [PMID: 38434203 PMCID: PMC10908552 DOI: 10.3389/fneur.2024.1300930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/07/2024] [Indexed: 03/05/2024] Open
Abstract
Purpose Cerebral vasospasm (CVS) is a common complication that occurs after neurosurgical clipping of intracranial aneurysms in patients with aSAH. This complication can lead to clinical deterioration and a poor prognosis. The aim of this study is to explore the risk factors for CVS in aSAH patients who have undergone neurosurgical clipping, develop a nomogram for CVS, and evaluate its performance. Methods Patients with aSAH who underwent neurosurgical clipping in the Department of Neurosurgery from January 2018 to January 2023 were selected as the subjects of this research. The clinical data of these patients were retrospectively analyzed. Logistic multivariate regression analysis was employed to identify the independent risk factors of CVS. A clinical prediction model in the form of a nomogram for CVS was developed using the R programming language and subsequently evaluated for its performance and quality. Results A total of 156 patients with aSAH were included in the analysis, comprising 109 patients in the training set and 47 patients in the validation set. In the training cohort, 27 patients (24.77%) developed CVS after neurosurgical clipping, while in the validation cohort, 15 patients (31.91%) experienced CVS. Multivariate regression analysis revealed that age, Hcy, WBC, glucose/potassium ratio, aneurysm location, and modified Fisher grade were independent risk factors for CVS. The nomogram exhibited excellent discriminative performance in both the training set (AUC = 0.885) and the validation set (AUC = 0.906). Conclusion CVS was a prevalent complication following neurosurgical clipping in patients with aSAH, with a highly intricate pathogenesis and pathophysiological course. Early prediction of CVS represented a significant challenge in clinical practice. In this study, age, Hcy, WBC, glucose/potassium ratio, aneurysm location, and modified Fisher grade emerged as independent risk factors for CVS. The resulting nomogram demonstrated substantial predictive value.
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Affiliation(s)
- Yu Zhou
- First Clinical Medical College, Lanzhou University, Lanzhou, China
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
| | - Dongliang Qian
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
| | - Zhou Zhou
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjing, China
- National Clinical Research Center for Chinese Medicine Acquisition and Moxibustion, Tianjin University of Traditional Chinese Medicine, Tianjing, China
| | - Bin Li
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
| | - Yong Ma
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
- Clinical Medicine College, Ningxia Medical University, Yinchuan, China
| | - Erqing Chai
- First Clinical Medical College, Lanzhou University, Lanzhou, China
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, China
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13
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Chen L, Jin Y, Wang L, Wei K, Li X, Jiang T, Cao X, Xue L, Cheng Q. Impact of human serum albumin level on symptomatic cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. Neurol Sci 2024; 45:213-222. [PMID: 37574504 DOI: 10.1007/s10072-023-07014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To investigate the impact of human serum albumin (HSA) levels on symptomatic cerebral vasospasm (SCVS) in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed the medical records. SCVS was defined as the development of a new neurological deterioration when the cause was considered to be ischemia attributable to vasospasm after other possible causes of worsening had been excluded. The aSAH patients were divided into two groups: those with SCVS (group 1) and those without SCVS (group 2). The HSA level data on the 1st, 2nd, and 3rd day after admission was collected. Multivariate logistical regression and receiver operating characteristic (ROC) analysis were performed to evaluate the ability of HSA level to predict the development of SCVS. RESULTS A total of 270 patients were included in our study, of which 74 (27.4%) developed SCVS. The average and lowest HSA levels were lower in group 1 (P < 0.001). In univariate logistic regression, white blood cell count, neutrophil count, and average and lowest HSA levels were associated with SCVS. After adjustment for age, CT Fisher grade, Hunt-Hess grade, and WFNS grade, both the average and lowest HSA levels remained independent predictors of SCVS (P < 0.001). The CT Fisher grade was confirmed to be an independent predictor of SCVS across each model. ROC analysis revealed that the lowest HSA level was a better predictor for SCVS than average HSA level and CT Fisher grade. CONCLUSION Clinicians are encouraged to measure HSA levels for the first 3 days after admission to predict the occurrence of SCVS after aSAH.
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Affiliation(s)
- Ling Chen
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Yang Jin
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huaian, Jiangsu, China
| | - Ling Wang
- Department of Neurology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Kai Wei
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Xin Li
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Tao Jiang
- Anhui Public Health Clinical Center, Hefei, China
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiangyang Cao
- Department of Neurology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huaian, Jiangsu, China.
| | - Liujun Xue
- Department of Neurology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, Jiangsu, China.
| | - Qiantao Cheng
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China.
- Anhui Public Health Clinical Center, Hefei, China.
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14
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Joos GS, Gottschalk A, Ewelt C, Holling M, Stummer W, Englbrecht JS. Risk factors associated with vasospasm after non-traumatic subarachnoid hemorrhage: a retrospective analysis of 456 patients. J Neurosurg Sci 2023; 67:576-584. [PMID: 35416450 DOI: 10.23736/s0390-5616.22.05497-2] [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: 11/08/2022]
Abstract
BACKGROUND The pathophysiology of vasospasm (VS) after non-traumatic subarachnoid hemorrhage is not completely understood. Several risk factors associated with VS were previously reported, partially with conflicting results. The aim of this study was to identify patients at increased risk for VS. METHODS Retrospective analysis of data from all patients treated in our institutional intensive care unit (ICU) between 2010 and 2016 after non-traumatic subarachnoid hemorrhage. Possible contributing factors for VS studied were: age, sex, aneurysm-localization, treatment option, ICU-stay, ICU mortality, pre-existing condition, medication history, World Federation of Neurosurgical Societies (WFNS) grading system, modified Fisher scale. RESULTS We obtained data from 456 patients. 184 were male and 272 female patients, respectively. Mean age was 57.7±13.9 and was not different between sexes. In 119 patients, VS was diagnosed after subarachnoid hemorrhage. Incidence of VS was not different between sexes (male: 22.3%, female: 28.7%, P=0.127). Patients with VS were significantly younger (mean age 52.2 vs. 59.7, P<0.001), meanwhile patients aged 36-40 yrs. had the highest incidence of VS. Most VS were found after rupture of middle cerebral artery-aneurysms. Higher incidence of VS was found after aneurysm clipping compared to coiling. VS developed more often in patients with more severe WFNS grade and Fisher scale. In multivariate analysis, age, previous drug abuse and history of anticoagulants were associated with the incidence of VS. CONCLUSIONS Younger age, middle cerebral artery-aneurysms, aneurysm clipping, previous drug abuse and history of anticoagulants were associated with a higher incidence of VS after non-traumatic subarachnoid hemorrhage. No gender difference was found.
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Affiliation(s)
- Gunther S Joos
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Antje Gottschalk
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Clinic Hamm-Heessen, Hamm, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Jan S Englbrecht
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany -
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15
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Mistry AM, Naidugari J, Feldman MJ, Magarik JA, Ding D, Abecassis IJ, Semler MW, Rice TW. Impact of Fludrocortisone on the Outcomes of Subarachnoid Hemorrhage Patients: A Retrospective Analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296246. [PMID: 37808869 PMCID: PMC10557818 DOI: 10.1101/2023.09.28.23296246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background Whether the use of fludrocortisone affects outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) and its usage rate in the United States remain unknown. Methods We conducted a retrospective analysis of 78 consecutive patients with a ruptured aSAH at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days. We adjusted the primary outcome for age, hypertension, aSAH grade, and time from aSAH onset to aneurysm treatment. Secondary outcomes were brain and cardiopulmonary dysfunction events. Results Among 78 patients at a single center, the median age was 58 years [IQR, 49 to 64.5]; 64% were female, and 41 (53%) received fludrocortisone. The adjusted common odds ratio, aOR, of a proportional odds regression model of fludrocortisone use with mRS was 0.33 (95% CI, 0.14-0.80; P=0.02), with values <1.0 favoring fludrocortisone. Organ-specific dysfunction events were not statistically different: delayed cerebral ischemia (22% vs. 39%, P=0.16); cardiac dysfunction (0% vs. 11%; P=0.10); and pulmonary edema (15% vs. 8%; P=0.59). Conclusions The risk of disability or death at 90 days was lower with the use of fludrocortisone in aSAH patients.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Michael J. Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jordan A. Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Isaac J. Abecassis
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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16
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Palmisciano P, Hoz SS, Johnson MD, Forbes JA, Prestigiacomo CJ, Zuccarello M, Andaluz N. External Validation of an Extreme Gradient Boosting Model for Prediction of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 175:e108-e114. [PMID: 36914029 DOI: 10.1016/j.wneu.2023.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) may significantly worsen the functional status of patients with aneurysmal subarachnoid hemorrhage (aSAH). Several authors have designed predictive models for early identification of patients at risk of post-aSAH DCI. In this study, we externally validate an extreme gradient boosting (EGB) forecasting model for post-aSAH DCI prediction. METHODS A 9-year institutional retrospective review of patients with aSAH was performed. Patients were included if they underwent surgical or endovascular treatment and had available follow-up data. DCI was diagnosed as new-onset neurologic deficits at 4-12 days after aneurysm rupture, defined as worsening Glasgow Coma Scale score for ≥2 points, and new ischemic infarcts at imaging. RESULTS We collected 267 patients with aSAH. At admission, median Hunt-Hess score was 2 (range, 1-5), median Fisher score 3 (range, 1-4), and median modified Fisher score 3 (range, 1-4). One-hundred and forty-five patients underwent external ventricular drainage placement for hydrocephalus (54.3%). The ruptured aneurysms were treated with clipping (64%), coiling (34.8%), and stent-assisted coiling (1.1%). Fifty-eight patients (21.7%) were diagnosed with clinical DCI and 82 (30.7%) with asymptomatic imaging vasospasm. The EGB classifier correctly predicted 19 cases of DCI (7.1%) and 154 cases of no-DCI (57.7%), achieving sensitivity of 32.76% and specificity of 73.68%. The calculated F1 score and accuracy were 0.288% and 64.8%, respectively. CONCLUSIONS We validated that the EGB model is a potential assistant tool to predict post-aSAH DCI in clinical practice, finding moderate-high specificity but low sensitivity. Future research should investigate the underlying pathophysiology of DCI to allow the development of high-performing forecasting models.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Samer S Hoz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mark D Johnson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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17
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Zhang W, Wang Y, Zhang Q, Hou F, Wang L, Zheng Z, Guo Y, Chen Z, Hernesniemi J, Feng G, Gu J. Prognostic significance of white blood cell to platelet ratio in delayed cerebral ischemia and long-term clinical outcome after aneurysmal subarachnoid hemorrhage. Front Neurol 2023; 14:1180178. [PMID: 37273707 PMCID: PMC10234150 DOI: 10.3389/fneur.2023.1180178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/09/2023] [Indexed: 06/06/2023] Open
Abstract
Objectives The ratio of white blood cell to platelet count (WPR) is considered a promising biomarker in some diseases. However, its prediction of delayed cerebral ischemia (DCI) and prognosis after aneurysmal subarachnoid hemorrhage (aSAH) has not been studied. The primary objective of this study was to investigate the predictive value of WPR in DCI after aSAH and its impact on 90-day functional outcome. Materials and methods This study retrospectively analyzed the data of blood biochemical parameters in 447 patients with aSAH at early admission. Univariate and multivariate analyses were used to determine the risk factors for DCI. According to multivariate analysis results, a nomogram for predicting DCI is developed and verified by R software. The influence of WPR on 90-day modified Rankin score (mRS) was also analyzed. Results Among 447 patients with aSAH, 117 (26.17%) developed DCI during hospitalization. Multivariate logistic regression analysis showed that WPR [OR = 1.236; 95%CI: 1.058-1.444; p = 0.007] was an independent risk factor for DCI. The receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive ability of WPR for DCI, and the cut-off value of 5.26 (AUC 0.804, 95% CI: 0.757-0.851, p < 0.001). The ROC curve (AUC 0.875, 95% CI: 0.836-0.913, p < 0.001) and calibration curve (mean absolute error = 0.017) showed that the nomogram had a good predictive ability for the occurrence of DCI. Finally, we also found that high WPR levels at admission were closely associated with poor prognosis. Conclusion WPR level at admission is a novel serum marker for DCI and the poor prognosis after aSAH. A nomogram model containing early WPR will be of great value in predicting DCI after aSAH.
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Affiliation(s)
- Wanwan Zhang
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- School of Clinical Medicine, Henan University, Kaifeng, China
| | - Yifei Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Qingqing Zhang
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- School of Clinical Medicine, Henan University, Kaifeng, China
| | - Fandi Hou
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Lintao Wang
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- School of Clinical Medicine, Henan University, Kaifeng, China
| | - Zhanqiang Zheng
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Yong Guo
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Zhongcan Chen
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Juha Hernesniemi
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Guang Feng
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Jianjun Gu
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
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18
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Vitt JR, Cheng RC, Chung J, Canton MT, Zhou B, Ko N, Meisel K, Amorim E. The Clinical Impact of Recent Methamphetamine Exposure in Aneurysmal Subarachnoid Patients. RESEARCH SQUARE 2023:rs.3.rs-2694424. [PMID: 37034745 PMCID: PMC10081452 DOI: 10.21203/rs.3.rs-2694424/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Background Methamphetamines (MA) are a frequently used drug class with potent sympathomimetic properties that can affect cerebral vasculature. Conflicting reports in literature exist about the effect of exposure to MA on vasospasm risk and clinical outcomes in aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to characterize the impact of recent MA use on the timing, severity and features of vasospasm in aneurysmal subarachnoid as well as neurological outcomes. Methods We retrospectively screened 441 consecutive patients admitted to a tertiary care hospital with a diagnosis of SAH who underwent at least one cerebral digital subtraction angiogram (DSA). Patients were excluded if no urinary toxicology screen was performed within 24 hours of admission, if there was a diagnosis of non-aneurysmal SAH, or if ictus was greater than 72 hours from hospital admission. Vasospasm characteristics were collected from DSA and transcranial doppler (TCD) studies and demographic as well as clinical outcome data was abstracted from the chart. Results 129 patients were included and 24 tested positive for MA. Among the 312 excluded patients, 281 did not have a urinary toxicology screen and 31 had a non-aneurysmal pattern of SAH or ictus occurring greater than 72 hours from hospital admission. No significant differences were found in respect to patient age, sex, or admission Hunt and Hess Score or Modified Fisher Scale based on MA use. There was no difference in the severity of vasospasm or time to peak severity using either TCD or DSA criteria on multivariate analysis. Aneurysms were more likely to be in the anterior circulation for both groups, however the MA cohort experienced less vasospasm involving the anterior circulation and more isolated posterior circulation vasospasm. There was no difference in delayed cerebral ischemia (DCI) incidence, length of ICU stay, need for ventriculoperitoneal shunt placement, functional outcome at discharge or hospital mortality. Interpretation Recent MA use was not associated with worse vasospasm severity, time to vasospasm, or DCI in aSAH patients. Further investigations about localized MA effects in the posterior circulation and impact on long-term functional outcomes are warranted.
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Affiliation(s)
| | | | - Jason Chung
- University of California San Francisco Department of Neurological Surgery
| | | | - Bo Zhou
- University of California San Francisco Weill Institute for Neurosciences
| | - Nerissa Ko
- University of California San Francisco Weill Institute for Neurosciences
| | - Karl Meisel
- University of California San Francisco Weill Institute for Neurosciences
| | - Ediberto Amorim
- University of California San Francisco Weill Institute for Neurosciences
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19
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Huang HY, Yuan B, Chen SJ, Han YL, Zhang X, Yu Q, Wu Q. A novel nomogram model for clinical outcomes of severe subarachnoid hemorrhage patients. Front Neurosci 2022; 16:1041548. [PMID: 36507324 PMCID: PMC9729550 DOI: 10.3389/fnins.2022.1041548] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
Background Systemic responses, especially inflammatory responses, after aneurysmal subarachnoid hemorrhage (SAH) are closely related to clinical outcomes. Our study aimed to explore the correlation between the systemic responses in the acute stage and the mid-term outcomes of severe SAH patients (Hunt-Hess grade III-V). Materials and methods Severe SAH patients admitted to Jinling Hospital from January 2015 to December 2019 were retrospectively analyzed in the study. The univariate and multivariate logistic regression analyses were used to explore the risk factors of 6-month clinical outcomes in severe SAH patients. A predictive model was established based on those risk factors and was visualized by a nomogram. Then, the predictive nomogram model was validated in another severe SAH patient cohort from January 2020 to January 2022. Results A total of 194 patients were enrolled in this study. 123 (63.4%, 123 of 194) patients achieved good clinical outcomes at the 6-month follow-up. Univariate and multivariate logistic regression analysis revealed that age, Hunt-Hess grade, neutrophil-to-lymphocyte ratio (NLR), and complications not related to operations were independent risk factors for unfavorable outcomes at 6-month follow-up. The areas under the curve (AUC) analysis showed that the predictive model based on the above four variables was significantly better than the Hunt-Hess grade (0.812 vs. 0.685, P = 0.013). In the validation cohort with 44 severe SAH patients from three different clinical centers, the AUC of the prognostic nomogram model was 0.893. Conclusion The predictive nomogram model could be a reliable predictive tool for the outcome of severe SAH patients. Systemic inflammatory responses after SAH and complications not related to operations, especially hydrocephalus, delayed cerebral ischemia, and pneumonia, might be the important risk factors that lead to poor outcomes in severe SAH patients.
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Affiliation(s)
- Han-Yu Huang
- Department of Neurosurgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China,Department of Neurosurgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China
| | - Bin Yuan
- Department of Neurosurgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China,Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Shu-Juan Chen
- Department of Neurosurgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China,Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Yan-ling Han
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China,Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Qing Yu
- Department of Clinical Laboratory, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China,*Correspondence: Qing Yu,
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China,Qi Wu,
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20
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Wang L. Letter to the Editor. Enteral volume loss and delayed cerebral ischemia. Neurosurg Focus 2022; 53:E13. [DOI: 10.3171/2022.6.focus22366] [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]
Affiliation(s)
- Lesheng Wang
- Zhongnan Hospital of Wuhan University, Wuhan, China
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21
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Said M, Dinger TF, Gümüs M, Rauschenbach L, Chihi M, Rodemerk J, Lenz V, Oppong MD, Uerschels AK, Dammann P, Wrede KH, Sure U, Jabbarli R. Impact of Anemia Severity on the Outcome of an Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2022; 11:jcm11216258. [PMID: 36362486 PMCID: PMC9657573 DOI: 10.3390/jcm11216258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: Previous reports indicate a negative impact of anemia on the outcome of an aneurysmal subarachnoid hemorrhage (SAH). We aimed to identify the outcome-relevant severity of post-SAH anemia. Methods: SAH cases treated at our institution between 01/2005 and 06/2016 were included (n = 640). The onset, duration, and severity (nadir hemoglobin (nHB) level) of anemia during the initial hospital stay were recorded. Study endpoints were new cerebral infarctions, a poor outcome six months post-SAH (modified Rankin scale > 3), and in-hospital mortality. To assess independent associations with the study endpoints, different multivariable regression models were performed, adjusted for relevant patient and baseline SAH characteristics as well as anemia-associated clinical events during the SAH. Results: The rates of anemia were 83.3%, 67.7%, 40.0%, 15.9%, and 4.5% for an nHB < 11 g/dL, < 10 g/dL, < 9 g/dL, < 8 g/dL, and < 7 g/dL, respectively. The higher the anemia severity, the later was the onset (post-SAH days 2, 4, 5.4, 7.6 and 8, p < 0.0001) and the shorter the duration (8 days, 6 days, 4 days, 3 days, and 2 days, p < 0.0001) of anemia. In the final multivariable analysis, only an nHB < 9 g/dL was independently associated with all study endpoints: adjusted odds ratio 1.7/3.22/2.44 for cerebral infarctions/in-hospital mortality/poor outcome. The timing (post-SAH day 3.9 vs. 6, p = 0.001) and duration (3 vs. 5 days, p = 0.041) of anemia with an nHB < 9 g/dL showed inverse associations with the risk of in-hospital mortality, but not with other study endpoints. Conclusions: Anemia is very common in SAH patients affecting four of five individuals during their hospital stay. An nHB decline to < 9 g/dL was strongly associated with all study endpoints, independent of baseline characteristics and SAH-related clinical events. Our data encourage further prospective evaluations of the value of different transfusion strategies in the functional outcomes of SAH patients.
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Affiliation(s)
- Maryam Said
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
- Correspondence: ; Tel.: +49-201-723-1201; Fax: +49-201-723-5909
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Meltem Gümüs
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Jan Rodemerk
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Veronika Lenz
- Institute of Transfusion Medicine, University Hospital of Essen, 45147 Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Anne-Kathrin Uerschels
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Karsten Henning Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
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22
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Solhpour A, Kumar S, Koch MJ, Doré S. Impact of blood component transfusions, tranexamic acid and fluids on subarachnoid hemorrhage outcomes. BRAIN HEMORRHAGES 2022. [DOI: 10.1016/j.hest.2022.10.002] [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] Open
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23
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Kelly PD, Yengo-Kahn AM, Tang AR, Jonathan SV, Reynolds RA, Ye F, Zhao Z, Froehler MT, Fusco MR, Morone PJ, Chitale RV. Conditional Vasospasm-Free Survival Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2022; 37:81-90. [PMID: 35099712 PMCID: PMC10949213 DOI: 10.1007/s12028-022-01444-z] [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: 08/08/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Following aneurysmal subarachnoid hemorrhage (SAH), patients are monitored closely for vasospasm in the intensive care unit. Conditional vasospasm-free survival describes the risk of future vasospasm as a function of time elapsed without vasospasm. Conditional survival has not been applied to this clinical scenario but could improve patient counseling and intensive care unit use. The objective of this study was to characterize conditional vasospasm-free survival following SAH. METHODS This was a single institution, retrospective cohort study of patients treated for aneurysmal SAH between 1/1/2000-6/1/2020. The primary outcome was the development of vasospasm defined by the first instance of either radiographic vasospasm on computed tomography angiography, Lindegaard Index > 3.0 by transcranial doppler ultrasonography, or vasospasm-specific intraarterial therapy. Multivariable Cox regression was performed, and conditional vasospasm-free survival curves were constructed. RESULTS A total of 528 patients were treated for aneurysmal SAH and 309 (58.5%) developed vasospasm. Conditional survival curves suggest patients who survive to postbleed day 10 without vasospasm have a nearly 90% chance of being discharged without vasospasm. The median onset of vasospasm was postbleed day 6. Age more than 50 years was associated with a lower risk (hazard ratio [HR] = .76; 95% confidence interval [CI] 0.64-0.91; p < 0.001). Higher initial systolic blood pressure (HR = 1.18; 95% CI 1.046-1.350; p = .008), Hunt-Hess grades 4 or 5 (HR = 1.304; 95% CI 1.014-1.676), and modified Fisher scale score of 4 (HR = 1.808; 95% CI 1.198-2.728) were associated with higher vasospasm than the respective lower grades. CONCLUSION Conditional survival provides a useful framework for counseling patients and making decisions around vasospasm risk for patients with aneurysmal SAH, while risk factor-stratified plots facilitate a patient-centric, evidence-based approach to these conversations and decisions.
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Affiliation(s)
- Patrick D Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University Medical Center, North T-4224, 1161 21st Avenue South , Nashville, TN, 37212, USA.
| | - Aaron M Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University Medical Center, North T-4224, 1161 21st Avenue South , Nashville, TN, 37212, USA
| | - Alan R Tang
- Vanderbilt University School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Sumeeth V Jonathan
- Vanderbilt University School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Rebecca A Reynolds
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University Medical Center, North T-4224, 1161 21st Avenue South , Nashville, TN, 37212, USA
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Michael T Froehler
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University Medical Center, North T-4224, 1161 21st Avenue South , Nashville, TN, 37212, USA
| | - Matthew R Fusco
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University Medical Center, North T-4224, 1161 21st Avenue South , Nashville, TN, 37212, USA
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University Medical Center, North T-4224, 1161 21st Avenue South , Nashville, TN, 37212, USA
| | - Rohan V Chitale
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University Medical Center, North T-4224, 1161 21st Avenue South , Nashville, TN, 37212, USA
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24
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Detecting Sepsis in Patients with Severe Subarachnoid Hemorrhage during Critical Care. J Clin Med 2022; 11:jcm11144229. [PMID: 35887994 PMCID: PMC9319068 DOI: 10.3390/jcm11144229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 01/27/2023] Open
Abstract
Introduction: Sepsis and septic shock continue to have a very high mortality rate. Therefore, the last consensus-based sepsis guideline introduced the sepsis related organ failure assessment (SOFA) score to ensure a rapid diagnosis and treatment of sepsis. In neurosurgical patients, especially those patients with subarachnoid hemorrhage (SAH), there are considerable difficulties in interpreting the SOFA score. Therefore, our study was designed to evaluate the applicability of the SOFA for critical care patients with subarachnoid hemorrhage. Methods: Our retrospective monocentric study was registered (NCT05246969) and approved by the local ethics committee (# 211/18). Patients admitted to the Department of Neurosurgery at the Frankfurt University Hospital were enrolled during the study period. Results: We included 57 patients with 85 sepsis episodes of which 141 patients had SOFA score-positive results and 243 SIRS positive detections. We failed to detect a correlation between the clinical diagnosis of sepsis and positive SOFA or SIRS scores. Moreover, a significant proportion of sepsis that was incorrectly detected via the SOFA score could be attributed to cerebral vasospasms (p < 0.01) or a decrease in Glasgow Coma Scale (p < 0.01). Similarly, a positive SIRS score was often not attributed to a septic episode (49.0%). Discussion: Regardless of the fact that SAH is a rare disease, the relevance of sepsis detection should be given special attention in light of the long duration of therapy and sepsis prevalence. Among the six modules represented by the SOFA score, two highly modules were practically eliminated. However, to enable early diagnosis of sepsis, the investigator’s clinical views and synopsis of various scores and laboratory parameters should be highlighted. Conclusions: In special patient populations, such as in critically ill SAH patients, the SOFA score can be limited regarding its applicability. In particular, it is very important to differentiate between CVS and sepsis.
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25
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Dicpinigaitis AJ, Feldstein E, Shapiro SD, Kamal H, Bauerschmidt A, Rosenberg J, Amuluru K, Pisapia J, Dangayach NS, Liang JW, Bowers CA, Mayer SA, Gandhi CD, Al-Mufti F. Cerebral vasospasm following arteriovenous malformation rupture: a population-based cross-sectional study. Neurosurg Focus 2022; 53:E15. [DOI: 10.3171/2022.4.focus2277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Studies examining the risk factors and clinical outcomes of arterial vasospasm secondary to cerebral arteriovenous malformation (cAVM) rupture are scarce in the literature. The authors used a population-based national registry to investigate this largely unexamined clinical entity.
METHODS
Admissions for adult patients with cAVM ruptures were identified in the National Inpatient Sample during the period from 2015 to 2019. Complex samples multivariable logistic regression and chi-square automatic interaction detection (CHAID) decision tree analyses were performed to identify significant associations between clinical covariates and the development of vasospasm, and a cAVM–vasospasm predictive model (cAVM-VPM) was generated based on the effect sizes of these parameters.
RESULTS
Among 7215 cAVM patients identified, 935 developed vasospasm, corresponding to an incidence rate of 13.0%; 110 of these patients (11.8%) subsequently progressed to delayed cerebral ischemia (DCI). Multivariable adjusted modeling identified the following baseline clinical covariates: decreasing age by decade (adjusted odds ratio [aOR] 0.87, 95% CI 0.83–0.92; p < 0.001), female sex (aOR 1.68, 95% CI 1.45–1.95; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.34, 95% CI 1.01–1.79; p = 0.045), intraventricular hemorrhage (aOR 1.87, 95% CI 1.17–2.98; p = 0.009), hypertension (aOR 1.77, 95% CI 1.50–2.08; p < 0.001), obesity (aOR 0.68, 95% CI 0.55–0.84; p < 0.001), congestive heart failure (aOR 1.34, 95% CI 1.01–1.78; p = 0.043), tobacco smoking (aOR 1.48, 95% CI 1.23–1.78; p < 0.019), and hospitalization events (leukocytosis [aOR 1.64, 95% CI 1.32–2.04; p < 0.001], hyponatremia [aOR 1.66, 95% CI 1.39–1.98; p < 0.001], and acute hypotension [aOR 1.67, 95% CI 1.31–2.11; p < 0.001]) independently associated with the development of vasospasm. Intraparenchymal and subarachnoid hemorrhage were not associated with the development of vasospasm following multivariable adjustment. Among significant associations, a CHAID decision tree algorithm identified age 50–59 years (parent node), hyponatremia, and leukocytosis as important determinants of vasospasm development. The cAVM-VPM achieved an area under the curve of 0.65 (sensitivity 0.70, specificity 0.53). Progression to DCI, but not vasospasm alone, was independently associated with in-hospital mortality (aOR 2.35, 95% CI 1.29–4.31; p = 0.016) and lower likelihood of routine discharge (aOR 0.62, 95% CI 0.41–0.96; p = 0.031).
CONCLUSIONS
This large-scale assessment of vasospasm in cAVM identifies common clinical risk factors and establishes progression to DCI as a predictor of poor neurological outcomes.
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Affiliation(s)
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Steven D. Shapiro
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | | | - Jon Rosenberg
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Carmel, Indiana
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Neha S. Dangayach
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York; and
| | - John W. Liang
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York; and
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico
| | - Stephan A. Mayer
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Chirag D. Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
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Zhao L, Cheng C, Peng L, Zuo W, Xiong D, Zhang L, Mao Z, Zhang J, Wu X, Jiang X, Wang P, Li W. Alcohol Abuse Associated With Increased Risk of Angiographic Vasospasm and Delayed Cerebral Ischemia in Patients With Aneurysmal Subarachnoid Hemorrhage Requiring Mechanical Ventilation. Front Cardiovasc Med 2022; 9:825890. [PMID: 35620515 PMCID: PMC9127604 DOI: 10.3389/fcvm.2022.825890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/21/2022] [Indexed: 01/01/2023] Open
Abstract
Objective Although alcohol abuse has been indicated to cause cerebral aneurysm development and rupture, there is limited data on the impact of alcohol abuse on outcomes after an aneurysmal subarachnoid hemorrhage (aSAH). This study aims to investigate whether alcohol abuse increases the risk of angiographic vasospasm and delayed cerebral ischemia (DCI) in critically ill patients with aSAH. Methods We conducted a secondary analysis based on a retrospective study in a French university hospital intensive care unit (ICU). Patients with aSAH requiring mechanical ventilation hospitalized between 2010 and 2015 were included. Patients were segregated according to alcohol abuse (yes or no). Multivariable logistic regression analysis was used to identify the independent risk factors associated with angiographic vasospasm and DCI. Results The patient proportion of alcohol abuse was dramatically greater in males than that in females (p < 0.001). The Simplified Acute Physiology Score II (SAPSII) score on admission did not show a statistical difference. Neither did the World Federation of Neurosurgical Societies (WFNS) and Fisher scores. Patients with alcohol abuse were more likely to develop angiographic vasospasm (OR 3.65, 95% CI 1.17–11.39; p = 0.0260) and DCI (OR 3.53, 95% CI 1.13–10.97; p = 0.0294) as evidenced by multivariable logistic regression analysis. Conclusions In this study, patients with alcohol abuse are at higher odds of angiographic vasospasm and DCI, which are related to poor prognosis following aSAH. These findings are important for the prevention and clinical management of aSAH.
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Affiliation(s)
- Lei Zhao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
- Lei Zhao
| | - Chao Cheng
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Wei Zuo
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Dong Xiong
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Lei Zhang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zilong Mao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jin'an Zhang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Xia Wu
- Department of Public Health, School of Health Sciences and Practice, New York Medical College, Valhalla, NY, United States
| | - Xue Jiang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Peng Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
- *Correspondence: Weixin Li
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27
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Strickland BA, Barisano G, Abedi A, Shiroishi MS, Cen S, Emanuel B, Bulic S, Kim-Tenser M, Nguyen P, Giannotta SL, Mack W, Russin J. Minocycline decreases blood-brain barrier permeability following aneurysmal subarachnoid hemorrhage: a randomized, double-blind, controlled trial. J Neurosurg 2022; 136:1251-1259. [PMID: 35349976 DOI: 10.3171/2021.6.jns211270] [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: 05/20/2021] [Accepted: 06/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH)-induced vasospasm is linked to increased inflammatory cell trafficking across a permeable blood-brain barrier (BBB). Elevations in serum levels of matrix metalloprotease 9 (MMP9), a BBB structural protein, have been implicated in the pathogenesis of vasospasm onset. Minocycline is a potent inhibitor of MMP9. The authors sought to detect an effect of minocycline on BBB permeability following aSAH. METHODS Patients presenting within 24 hours of symptom onset with imaging confirmed aSAH (Fisher grade 3 or 4) were randomized to high-dose (10 mg/kg) minocycline or placebo. The primary outcome of interest was BBB permeability as quantitated by contrast signal intensity ratios in vascular regions of interest on postbleed day (PBD) 5 magnetic resonance permeability imaging. Secondary outcomes included serum MMP9 levels and radiographic and clinical evidence of vasospasm. RESULTS A total of 11 patients were randomized to minocycline (n = 6) or control (n = 5) groups. No adverse events or complications attributable to minocycline were reported. High-dose minocycline administration was associated with significantly lower permeability indices on imaging analysis (p < 0.01). There was no significant difference with respect to serum MMP9 levels between groups, although concentrations trended upward in both cohorts. Radiographic vasospasm was noted in 6 patients (minocycline = 3, control = 3), with only 1 patient developing symptoms of clinical vasospasm in the minocycline cohort. There was no difference between cohorts with respect to Lindegaard ratios, transcranial Doppler values, or onset of vasospasm. CONCLUSIONS Minocycline at high doses is well tolerated in the ruptured cerebral aneurysm population. Minocycline curtails breakdown of the BBB following aSAH as evidenced by lower permeability indices, though minocycline did not significantly alter serum MMP9 levels. Larger randomized clinical trials are needed to assess minocycline as a neuroprotectant against aSAH-induced vasospasm. Clinical trial registration no.: NCT04876638 (clinicaltrials.gov).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Jonathan Russin
- 1Departments of Neurosurgery
- 5Neurorestoration Center, University of Southern California, Los Angeles, California
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28
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Wahood W, Rizvi AA, Alexander AY, Yolcu YU, Lanzino G, Brinjikji W, Rabinstein AA. Trends in Admissions and Outcomes for Treatment of Aneurysmal Subarachnoid Hemorrhage in the United States. Neurocrit Care 2022; 37:209-218. [PMID: 35304707 DOI: 10.1007/s12028-022-01476-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/22/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lifestyle modifications and advances in surgical and endovascular techniques for treating unruptured intracranial aneurysm (UIA) have vastly evolved over the last few decades and may have reduced the incidence of aneurysmal subarachnoid hemorrhage (aSAH). However, the actual impact of these changes on the rates and outcomes of aSAH remain unexplored. Thus, we studied national aSAH admissions and outcome trends and changes of major risk factors over time. METHODS We queried the National Inpatient Sample between 2006 and 2018 to identify adult patients admitted and treated for UIA or ruptured aneurysm with aSAH. The Cochran-Armitage test was conducted to assess the linear trend of proportion of prevalence, inpatient mortality, hypertension, and current smoking status among aSAH admissions. Multivariable logistic regression was conducted to assess the odds of presenting with aSAH versus UIA, in addition to the odds of inpatient mortality among patients with aSAH. RESULTS A total of 159,913 patients presented with UIA and 133,567 presented with aSAH. Admissions for aSAH decreased by 0.97% (p < 0.001) per year. Current smoking and hypertension were associated with higher odds of being admitted for aSAH compared with the treatment for UIA (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.29-1.48; OR 1.15, 95% CI 1.08-1.22, respectively). Compared with White patients, Black patients (OR 1.32, 95% CI 1.21-1.43), Hispanic patients (OR 1.38, 95% CI 1.25-1.52), and patients of other races and/or ethnicities (OR 1.73, 95% CI 1.54-1.95) had a higher chance of presenting with aSAH. Rates of inpatient mortality among aSAH admissions showed no change over time (p = 0.21). Among patients admitted with aSAH, current smoking and hypertension showed an upward trend of 0.58% (p < 0.001) and 1.60% (p < 0.001) per year, respectively. CONCLUSIONS Despite a downward trend in the annual frequency of hospitalizations for aSAH, inpatient mortality rates for patients undergoing treatment of the ruptured aneurysm have remained unchanged in the United States. Smoking and hypertension are increasingly prevalent among patients with aSAH. Thus, efforts to control these modifiable risk factors must be further strengthened.
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Affiliation(s)
- Waseem Wahood
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, 3200 University Drive, Davie, FL, 33328, USA.
| | - Ahraz Ahsan Rizvi
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, 3200 University Drive, Davie, FL, 33328, USA
| | | | | | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Li L, Fu X, Qiu H, Shi P. Effects of cilostazol treatment for patients with aneurysmal subarachnoid hemorrhage: A meta-analysis of 14 studies. J Clin Neurosci 2022; 99:190-203. [PMID: 35286971 DOI: 10.1016/j.jocn.2021.12.025] [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: 09/25/2021] [Revised: 12/04/2021] [Accepted: 12/21/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To perform an updated meta-analysis to comprehensively assess the efficacy and safety of cilostazol in preventing aneurysmal subarachnoid hemorrhage (SAH)-related secondary complications. METHODS Electronic databases of PubMed, the Cochrane library, CNKI and Wanfang were searched on August 2021. Pooled odds ratio (OR) and standardized mean difference (SMD) were calculated for dichotomous and continuous outcomes, respectively. RESULTS A total of 14 studies [comprising 18,726 aneurysmal SAH patients (6654 in the cilostazol group and 12,072 in the control group)] performed in Japan or China were included. Compared with the control group, cilostazol treatment significantly reduced the median cerebral artery (SMD = -0.49; p < 0.001), improved the therapeutic efficacy (OR = 2.37; p = 0.009), decreased the incidence of symptomatic vasospasm/delayed cerebral ischemia (OR = 0.42; p < 0.001), severe angiographic vasospasm (OR = 0.54; p < 0.001), new cerebral infarction (OR = 0.33; p < 0.001), poor outcomes (OR = 0.86; p = 0.001), mortality (OR = 0.62; p < 0.001) and increased the incidence of no or mild angiographic vasospasm (OR = 1.94; p = 0.004), but did not induce more adverse events (OR = 1.08; p = 0.871). The mechanism of cilostazol treatment was to inhibit the production of tenascin-C (SMD = -1.46; p < 0.001). These results were hardly changed by subgroup analysis. CONCLUSION This meta-analysis indicates cilostazol may be an effective and safe drug for aneurysmal SAH patients. However, further trials involving other world populations are required to demonstrate the generalization of treatment effects of cilostazol.
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Affiliation(s)
- Lian Li
- Emergency Department, Hongqiao Branch, Huashan Hospital Affiliated to Fudan University, Shanghai 200052, China
| | - Xiaofeng Fu
- Emergency Department, Hongqiao Branch, Huashan Hospital Affiliated to Fudan University, Shanghai 200052, China
| | - Huiming Qiu
- 80w Ward, Pudong Branch, Huashan Hospital Affiliated to Fudan University, Shanghai 200120, China.
| | - Peihong Shi
- Emergency Department, Hongqiao Branch, Huashan Hospital Affiliated to Fudan University, Shanghai 200052, China
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Dicpinigaitis AJ, Feldstein E, Damodara N, Cooper JB, Shapiro SD, Kamal H, Kinon MD, Pisapia J, Rosenberg J, Gandhi CD, Al-Mufti F. Development of cerebral vasospasm following traumatic intracranial hemorrhage: incidence, risk factors, and clinical outcomes. Neurosurg Focus 2022; 52:E14. [DOI: 10.3171/2021.12.focus21668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Limited evidence exists characterizing the incidence, risk factors, and clinical associations of cerebral vasospasm following traumatic intracranial hemorrhage (tICH) on a large scale. Therefore, the authors sought to use data from a national inpatient registry to investigate these aspects of posttraumatic vasospasm (PTV) to further elucidate potential causes of neurological morbidity and mortality subsequent to the initial insult.
METHODS
Weighted discharge data from the National (Nationwide) Inpatient Sample from 2015 to 2018 were queried to identify patients with tICH who underwent diagnostic angiography in the same admission and, subsequently, those who developed angiographically confirmed cerebral vasospasm. Multivariable logistic regression analysis was performed to identify significant associations between clinical covariates and the development of vasospasm, and a tICH vasospasm predictive model (tICH-VPM) was generated based on the effect sizes of these parameters.
RESULTS
Among 5880 identified patients with tICH, 375 developed PTV corresponding to an incidence of 6.4%. Multivariable adjusted modeling determined that the following clinical covariates were independently associated with the development of PTV, among others: age (adjusted odds ratio [aOR] 0.98, 95% CI 0.97–0.99; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.80, 95% CI 1.12–2.90; p = 0.015), intraventricular hemorrhage (aOR 6.27, 95% CI 3.49–11.26; p < 0.001), tobacco smoking (aOR 1.36, 95% CI 1.02–1.80; p = 0.035), cocaine use (aOR 3.62, 95% CI 1.97–6.63; p < 0.001), fever (aOR 2.09, 95% CI 1.34–3.27; p = 0.001), and hypokalemia (aOR 1.62, 95% CI 1.26–2.08; p < 0.001). The tICH-VPM achieved moderately high discrimination, with an area under the curve of 0.75 (sensitivity = 0.61 and specificity = 0.81). Development of vasospasm was independently associated with a lower likelihood of routine discharge (aOR 0.60, 95% CI 0.45–0.78; p < 0.001) and an extended hospital length of stay (aOR 3.53, 95% CI 2.78–4.48; p < 0.001), but not with mortality.
CONCLUSIONS
This population-based analysis of vasospasm in tICH has identified common clinical risk factors for its development, and has established an independent association between the development of vasospasm and poorer neurological outcomes.
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Affiliation(s)
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, and
| | | | | | | | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, and
| | | | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, and
| | - Jon Rosenberg
- Department of Neurology, Westchester Medical Center, Valhalla, New York
| | | | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, and
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Leukocytosis and C-Reactive Protein May Predict Development of Secondary Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage. Medicina (B Aires) 2022; 58:medicina58020323. [PMID: 35208646 PMCID: PMC8880412 DOI: 10.3390/medicina58020323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/12/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Secondary cerebral vasospasm (CV) with subsequent delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) remains an unpredictable pathology. The aim of this retrospective study was to investigate the association between inflammatory parameters, white blood cell (WBC) count, and C-reactive protein plasma levels (CRP) and the occurrence of secondary CV in patients with aSAH. Materials and Methods: The medical records of 201 Intensive Care Unit patients in Riga East University Hospital with aSAH were retrospectively reviewed in a 24-month period. WBC count and CRP values were observed at admission to the hospital and on the third day. According to the inclusion criteria, 117 (48 males) participants were enrolled for further analysis, with average age of 56 ± 15 years (mean ± SD). In total, secondary CV was diagnosed in 21.4% of cases, and DCI in 22.4% of cases. The patients were classified into three groups: SAH-CV group (n = 25), SAH-DCI group (n = 12), and SAH or control group (n = 80), for comparative analysis. Results: We found that SAH-CV patients demonstrated notably higher inflammatory parameters compared to controls: WBC 13.2 ± 3.3 × 109/L vs. 11.2 ± 3.7 × 109/L; p = 0.01 and CRP median 9.3 mg/L vs. 1.9 mg/L; p < 0.001, respectively. We found that the odds of developing CV increased by 5% for each CRP increase of 1 mg/L at admission (OR, 1.05; CI, 1.014–1.087; p = 0.006). Concomitantly, the odds increased by 16% for every rise in WBC count of 1 × 109/L (OR, 1.16; CI, 1.02–1.32; p = 0.02). WBC count was associated with the occurrence of CV with 96% sensitivity and 40% specificity, with a cut off level of 10.015 × 109/L and AUC 0.683; p = 0.006. CRP displayed 54% sensitivity and 90% specificity with a cut off value of 8.9 mg/L and AUC 0.751; p < 0.001. Moreover, higher values of inflammatory parameters at admission correlated with a longer stay in ICU (r = 0.3, p = 0.002 for WBC count and r = 0.305, p = 0.002 for CRP values), and poor outcome (death) was significantly associated with higher CRP values at admission and on the third day (16.1. vs. 2.2. and 57.4. vs. 11.1, p < 0.001, respectively). Higher mortality was detected in SAH-CV patients (32%) compared to controls (6.3%; p < 0.001). Conclusions: Inflammatory parameters such as WBC count and CRP values at admission might be helpful to predict the development of secondary CV.
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Bobeff EJ, Bukowiecka-Matusiak M, Stawiski K, Wiśniewski K, Burzynska-Pedziwiatr I, Kordzińska M, Kowalski K, Sendys P, Piotrowski M, Szczesna D, Stefańczyk L, Wozniak LA, Jaskólski DJ. Plasma Amino Acids May Improve Prediction Accuracy of Cerebral Vasospasm after Aneurysmal Subarachnoid Haemorrhage. J Clin Med 2022; 11:jcm11020380. [PMID: 35054073 PMCID: PMC8779950 DOI: 10.3390/jcm11020380] [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: 11/02/2021] [Revised: 12/25/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022] Open
Abstract
Aneurysmal subarachnoid haemorrhages (aSAH) account for 5% of strokes and continues to place a great burden on patients and their families. Cerebral vasospasm (CVS) is one of the main causes of death after aSAH, and is usually diagnosed between day 3 and 14 after bleeding. Its pathogenesis remains poorly understood. To verify whether plasma concentration of amino acids have prognostic value in predicting CVS, we analysed data from 35 patients after aSAH (median age 55 years, IQR 39-62; 20 females, 57.1%), and 37 healthy volunteers (median age 50 years, IQR 38-56; 19 females, 51.4%). Fasting peripheral blood samples were collected on postoperative day one and seven. High performance liquid chromatography-mass spectrometry (HPLC-MS) analysis was performed. The results showed that plasma from patients after aSAH featured a distinctive amino acids concentration which was presented in both principal component analysis and direct comparison. No significant differences were noted between postoperative day one and seven. A total of 18 patients from the study group (51.4%) developed CVS. Hydroxyproline (AUC = 0.7042, 95%CI 0.5259-0.8826, p = 0.0248) and phenylalanine (AUC = 0.6944, 95%CI 0.5119-0.877, p = 0.0368) presented significant CVS prediction potential. Combining the Hunt-Hess Scale and plasma levels of hydroxyproline and phenylalanine provided the model with the best predictive performance and the lowest leave-one-out cross-validation of performance error. Our results suggest that plasma amino acids may improve sensitivity and specificity of Hunt-Hess scale in predicting CVS.
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Affiliation(s)
- Ernest Jan Bobeff
- Department of Neurosurgery and Neuro-Oncology, Medical University of Lodz, Barlicki University Hospital, Kopcinskiego St. 22, 90-153 Lodz, Poland; (K.W.); (M.P.); (D.J.J.)
- Correspondence: ; Tel.: +48-42-677-6770; Fax: +48-42-677-6781
| | - Malgorzata Bukowiecka-Matusiak
- Department of Structural Biology, Medical University of Lodz, 90-419 Lodz, Poland; (M.B.-M.); (I.B.-P.); (D.S.); (L.A.W.)
| | - Konrad Stawiski
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Mazowiecka 15 Street, 92-215 Lodz, Poland;
| | - Karol Wiśniewski
- Department of Neurosurgery and Neuro-Oncology, Medical University of Lodz, Barlicki University Hospital, Kopcinskiego St. 22, 90-153 Lodz, Poland; (K.W.); (M.P.); (D.J.J.)
| | - Izabela Burzynska-Pedziwiatr
- Department of Structural Biology, Medical University of Lodz, 90-419 Lodz, Poland; (M.B.-M.); (I.B.-P.); (D.S.); (L.A.W.)
| | - Magdalena Kordzińska
- Department of Radiology, Barlicki Memorial Teaching Hospital, Medical University of Lodz, Kopcinskiego 22 Street, 90-153 Lodz, Poland; (M.K.); (L.S.)
| | - Konrad Kowalski
- Laboratorium Diagnostyczne Masdiag, ul. Żeromskiego 33, 01-882 Warszawa, Poland; (K.K.); (P.S.)
| | - Przemyslaw Sendys
- Laboratorium Diagnostyczne Masdiag, ul. Żeromskiego 33, 01-882 Warszawa, Poland; (K.K.); (P.S.)
| | - Michał Piotrowski
- Department of Neurosurgery and Neuro-Oncology, Medical University of Lodz, Barlicki University Hospital, Kopcinskiego St. 22, 90-153 Lodz, Poland; (K.W.); (M.P.); (D.J.J.)
| | - Dorota Szczesna
- Department of Structural Biology, Medical University of Lodz, 90-419 Lodz, Poland; (M.B.-M.); (I.B.-P.); (D.S.); (L.A.W.)
| | - Ludomir Stefańczyk
- Department of Radiology, Barlicki Memorial Teaching Hospital, Medical University of Lodz, Kopcinskiego 22 Street, 90-153 Lodz, Poland; (M.K.); (L.S.)
| | - Lucyna Alicja Wozniak
- Department of Structural Biology, Medical University of Lodz, 90-419 Lodz, Poland; (M.B.-M.); (I.B.-P.); (D.S.); (L.A.W.)
| | - Dariusz Jan Jaskólski
- Department of Neurosurgery and Neuro-Oncology, Medical University of Lodz, Barlicki University Hospital, Kopcinskiego St. 22, 90-153 Lodz, Poland; (K.W.); (M.P.); (D.J.J.)
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Affiliation(s)
- Feras Akbik
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
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34
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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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35
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Alexopoulos G, Zhang J, Karampelas I, Khan M, Quadri N, Patel M, Patel N, Almajali M, Mattei TA, Kemp J, Coppens J, Mercier P. Applied forecasting for delayed cerebral ischemia prediction post subarachnoid hemorrhage: Methodological fallacies. INFORMATICS IN MEDICINE UNLOCKED 2022. [DOI: 10.1016/j.imu.2021.100817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Alhaj AK, Yousef W, Alanezi A, Almutawa M, Zaidan S, Alsheikh TM, Abdulghaffar M, Al-Saadi T, Cavallo LM, Savic D. Does establishing a neurovascular unit improve the outcome after surgical clipping for aneurysmal subarachnoid hemorrhage? Results from a 5-year observational study in Kuwait. Surg Neurol Int 2021; 12:547. [PMID: 34877033 PMCID: PMC8645493 DOI: 10.25259/sni_914_2021] [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: 09/06/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Failure to prevent rebleeding after cerebral subarachnoid hemorrhage (SAH) is the most frequent reason for high morbidity and mortality of aneurysmal SAH. Our study aims to identify the outcome after surgical clipping of aneurysmal SAH before and after the establishment of the neurovascular unit. The clarifications of the positive turnover in the outcome will be discussed. Methods: A retrospective cohort analysis was carried out on our experience with a controlled group of patients who underwent clipping for ruptured cerebral aneurysms (n = 61) from January 2015 to December 2019. A modified Rankin scale (mRS) was used to determine the outcome after 6 months of follow-up. Results: The median mRS score (i.e., outcome) on admission was 4, whereas it was with a median score of 2 six months after clipping (P ≤ 0.001). Overall, the cases with a good outcome were 63.9% of the sample, while the poor outcome conditions were 36.1%. The most cases with an improved outcome were after introducing the neurovascular unit, representing a transition of aneurysmal clipping practice in our center. The good outcome was changed from 42% to 76.7%, and the poor outcome was changed from 58% to 23.3% (P = 0.019). The crude mortality rate was similar to the rate worldwide (18%), with a noticeable decrease after organizing a neurovascular subspecialty. Conclusion: The outcome after clipping of ruptured SAH can be largely affected by the surgeon’s experience and postoperative intensive care. Organizing a neurovascular team is one of the major factors to achieve good outcomes.
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Affiliation(s)
- Ahmad Kh Alhaj
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Waleed Yousef
- Department of Neurosurgery, Ibn Sina Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Abdulrahman Alanezi
- Department of Neurosurgery, Ibn Sina Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Mariam Almutawa
- Kuwait Medical School, Health Sciences Center, Kuwait University, Jabriya, Kuwait
| | - Salem Zaidan
- Department of Neurosurgery, Ibn Sina Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Tarik M Alsheikh
- Department of Neurosurgery, Ibn Sina Hospital, Ministry of Health, Kuwait City, Kuwait
| | | | - Tariq Al-Saadi
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Luigi M Cavallo
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli Federico II, Naples, Italy
| | - Dragan Savic
- Department of Neurosurgery, Ibn Sina Hospital, Ministry of Health, Kuwait City, Kuwait
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Geraghty JR, Lung TJ, Hirsch Y, Katz EA, Cheng T, Saini NS, Pandey DK, Testai FD. Systemic Immune-Inflammation Index Predicts Delayed Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2021; 89:1071-1079. [PMID: 34560777 PMCID: PMC8600162 DOI: 10.1093/neuros/nyab354] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/31/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Delayed cerebral vasospasm is a feared complication of aneurysmal subarachnoid hemorrhage (SAH). OBJECTIVE To investigate the relationship of systemic inflammation, measured using the systemic immune-inflammation (SII) index, with delayed angiographic or sonographic vasospasm. We hypothesize that early elevations in SII index serve as an independent predictor of vasospasm. METHODS We retrospectively reviewed the medical records of 289 SAH patients for angiographic or sonographic evidence of delayed cerebral vasospasm. SII index [(neutrophils × platelets/lymphocytes)/1000] was calculated from laboratory data at admission and dichotomized based on whether or not the patient developed vasospasm. Multivariable logistic regression and receiver operating characteristic (ROC) analysis were performed to determine the ability of SII index to predict the development of vasospasm. RESULTS A total of 246 patients were included in our study, of which 166 (67.5%) developed angiographic or sonographic evidence of cerebral vasospasm. Admission SII index was elevated for SAH in patients with vasospasm compared to those without (P < .001). In univariate logistic regression, leukocytes, neutrophils, lymphocytes, neutrophil-lymphocyte ratio (NLR), and SII index were associated with vasospasm. After adjustment for age, aneurysm location, diabetes mellitus, hyperlipidemia, and modified Fisher scale, SII index remained an independent predictor of vasospasm (odds ratio 1.386, P = .003). ROC analysis revealed that SII index accurately distinguished between patients who develop vasospasm vs those who do not (area under the curve = 0.767, P < .001). CONCLUSION Early elevation in SII index can independently predict the development of delayed cerebral vasospasm in aneurysmal SAH.
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Affiliation(s)
- Joseph R Geraghty
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Tyler J Lung
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Yonatan Hirsch
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Eitan A Katz
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Tiffany Cheng
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Neil S Saini
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Dilip K Pandey
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, Illinois, USA
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Maciel CB. Neurologic Outcome Prediction in the Intensive Care Unit. Continuum (Minneap Minn) 2021; 27:1405-1429. [PMID: 34618766 DOI: 10.1212/con.0000000000001053] [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: 11/15/2022]
Abstract
PURPOSE OF REVIEW The burden of severe and disabling neurologic injury on survivors, families, and society can be profound. Neurologic outcome prediction, or neuroprognostication, is a complex undertaking with many important ramifications. It allows patients with good prognoses to be supported aggressively, survive, and recover; conversely, it avoids inappropriate prolonged and costly care in those with devastating injuries. RECENT FINDINGS Striving to maintain a high prediction performance during prognostic assessments encompasses acknowledging the shortcomings of this task and the challenges created by advances in medicine, which constantly shift the natural history of neurologic conditions. Embracing the unknowns of outcome prediction and the boundaries of knowledge surrounding neurologic recovery and plasticity is a necessary step toward refining neuroprognostication practices and improving the accuracy of prognostic impressions. The pillars of modern neuroprognostication include comprehensive characterization of neurologic injury burden (primary and secondary injuries), gauging cerebral resilience and estimated neurologic reserve, and tying it all together with individual values surrounding the acceptable extent of disability and the difficulties of an arduous convalescence journey. SUMMARY Comprehensive multimodal frameworks of neuroprognostication using different prognostic tools to portray the burden of neurologic injury coupled with the characterization of individual values and the degree of cerebral reserve and resilience are the cornerstone of modern outcome prediction.
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Lakhal K, Hivert A, Alexandre PL, Fresco M, Robert-Edan V, Rodie-Talbere PA, Ambrosi X, Bourcier R, Rozec B, Cadiet J. Intravenous Milrinone for Cerebral Vasospasm in Subarachnoid Hemorrhage: The MILRISPASM Controlled Before-After Study. Neurocrit Care 2021; 35:669-679. [PMID: 34478028 DOI: 10.1007/s12028-021-01331-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intravenous (IV) milrinone, in combination with induced hypertension, has been proposed as a treatment option for cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). However, data on its safety and efficacy are scarce. METHODS This was a controlled observational study conducted in an academic hospital with prospectively and retrospectively collected data. Consecutive patients with cerebral vasospasm following aSAH and treated with both IV milrinone (0.5 µg/kg/min-1, as part of a strict protocol) and induced hypertension were compared with a historical control group receiving hypertension alone. Multivariable analyses aimed at minimizing potential biases. We assessed (1) 6-month functional disability (defined as a score between 2 and 6 on the modified Rankin Scale) and vasospasm-related brain infarction, (2) the rate of first-line or rescue endovascular angioplasty for vasospasm, and (3) immediate tolerance to IV milrinone. RESULTS Ninety-four patients were included (41 and 53 in the IV milrinone and the control group, respectively). IV milrinone infusion was independently associated with a lower likelihood of 6-month functional disability (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.10-0.77]) and vasospasm-related brain infarction (aOR = 0.19, 95% CI 0.04-0.94). Endovascular angioplasty was less frequent in the IV milrinone group (6 [15%] vs. 28 [53%] patients, p = 0.0001, aOR = 0.12, 95% CI 0.04-0.38). IV milrinone (median duration of infusion, 5 [2-8] days) was prematurely discontinued owing to poor tolerance in 12 patients, mostly (n = 10) for "non/hardly-attained induced hypertension" (mean arterial blood pressure < 100 mmHg despite 1.5 µg/kg/min-1 of norepinephrine). However, this event was similarly observed in IV milrinone and control patients (n = 10 [24%] vs. n = 11 [21%], respectively, p = 0.68). IV milrinone was associated with a higher incidence of polyuria (IV milrinone patients had creatinine clearance of 191 [153-238] ml/min-1) and hyponatremia or hypokalemia, whereas arrhythmia, myocardial ischemia, and thrombocytopenia were infrequent. CONCLUSIONS Despite its premature discontinuation in 29% of patients as a result of its poor tolerance, IV milrinone was associated with a lower rate of endovascular angioplasty and a positive impact on long-term neurological and radiological outcomes. These preliminary findings encourage the conduction of confirmatory randomized trials.
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Affiliation(s)
- Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France.
| | - Antoine Hivert
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Pierre-Louis Alexandre
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Marion Fresco
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Pierre-André Rodie-Talbere
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Xavier Ambrosi
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
| | - Romain Bourcier
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France.,Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France.,Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
| | - Julien Cadiet
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes Cedex 1, France
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Mishra S, Garg K, Gaonkar VB, Singh PM, Singh M, Suri A, Chandra PS, Kale SS. Effects of Various Therapeutic Agents on Vasospasm and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage-Results of a Network Meta-Analysis. World Neurosurg 2021; 155:41-53. [PMID: 34339892 DOI: 10.1016/j.wneu.2021.07.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Vasospasm and delayed ischemic neurologic deficits are the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Several therapeutic agents have been assessed in randomized controlled trials for their efficacy in reducing the incidence of vasospasm and improving functional outcome. The aim of this network meta-analysis is to compare all these therapeutic agents for their effect on functional outcome and other parameters after aSAH. METHODS A comprehensive search of different databases was performed to retrieve randomized controlled trials describing the effect of various therapeutic approaches on functional outcome and other parameters after aSAH. RESULTS Ninety-two articles were selected for full text review and 57 articles were selected for the final analysis. Nicardipine prolonged-release implants were found to be the best treatment in terms of favorable outcome (odds ratio [OR], 8.55; 95% credible interval [CrI], 1.63-56.71), decreasing mortality (OR, 0.08; 95% CrI, 0-0.82), and preventing angiographic vasospasm (OR, 0.018; 95% CrI, 0.00057-0.16). Cilostazol was found to be the second-best treatment in improving favorable outcomes (OR, 3.58; 95% CrI, 1.97-6.57) and decreasing mortality (OR, 0.41; 95% CrI, 0.12-1.15). Fasudil (OR, 0.16; 95% CrI, 0.03-0.78) was found to be the best treatment in decreasing increased vessel velocity and enoxaparin (OR, 0.25; 95% CrI, 0.057-1.0) in preventing delayed ischemic neurologic deficits. CONCLUSIONS Our analysis showed that nicardipine prolonged-release implants and cilostazol were associated with the best chance of improving favorable outcome and mortality in patients with aSAH. However, larger multicentric studies from other parts of the world are required to confirm these findings.
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Affiliation(s)
- Sandeep Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India.
| | - Vishwa Bharathi Gaonkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Preet Mohinder Singh
- Department of Anesthesia, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Goal-directed Fluid Therapy Versus Conventional Fluid Therapy During Craniotomy and Clipping of Cerebral Aneurysm: A Prospective Randomized Controlled Trial. J Neurosurg Anesthesiol 2021; 34:407-414. [PMID: 33835084 DOI: 10.1097/ana.0000000000000769] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fluid imbalance is common after aneurysmal subarachnoid hemorrhage and negatively impacts clinical outcomes. We compared intraoperative goal-directed fluid therapy (GDFT) using left ventricular outflow tract velocity time integral (LVOT-VTI) measured by transesophageal echocardiography with central venous pressure (CVP)-guided fluid therapy during aneurysm clipping in aneurysmal subarachnoid hemorrhage patients. METHODS Fifty adults scheduled for urgent craniotomy for aneurysm clipping were randomly allocated to 2 groups: group G (n=25) received GDFT guided by LVOT-VTI and group C (n=25) received CVP-guided fluid management. The primary outcome was intraoperative mean arterial pressure (MAP). Secondary outcomes included volume of fluid administered and several other intraoperative and postoperative variables, including neurological outcome at hospital discharge and at 30 and 90 days. RESULTS There was no difference in MAP between the 2 groups despite patients in group G receiving lower volumes of fluid compared with patients in group C (2503.6±534.3 vs. 3732.8±676.5 mL, respectively; P<0.0001). Heart rate and diastolic blood pressure were also comparable between groups, whereas systolic blood pressure was higher in group G than in group C at several intraoperative time points. Other intraoperative variables, including blood loss, urine output, and lactate levels were not different between the 2 groups. Postoperative variables, including creatinine, duration of postoperative mechanical ventilation, length of intensive care unit and hospital stay, and incidence of acute kidney injury, pneumonitis, and vasospasm were also comparable between groups. There was no difference in neurological outcome at hospital discharge (modified Rankin scale) and at 30 and 90 days (Extended Glasgow Outcome Scale) between the 2 groups. CONCLUSION Compared with CVP-guided fluid therapy, transesophageal echocardiography-guided GDFT maintains MAP with lower volumes of intravenous fluid in patients undergoing clipping of intracranial aneurysms with no adverse impact on postoperative complications.
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