Management of the Ruptured Aneurysm

Effect of Peri-operative Blood Transfusion on Neurological Outcome Following Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Study

BACKGROUND

Anemia is a common complication of aneurysmal subarachnoid hemorrhage and is associated with unfavorable outcomes. Whether the physiological benefits of transfusion for anemia surpass the risk of blood transfusion remains to be determined.

OBJECTIVES

The primary outcome was to evaluate the impact of peri-operative blood transfusion on the long-term neurological outcome, assessed by Glasgow Outcome Scale Extended at 3 months. The secondary outcomes included the impact of transfusion on the short-term neurological outcome, assessed by Modified Rankin Score at discharge/7 days, and on the incidence of vasospasm, infarction, re-exploration, tracheostomy, and length of hospital stay.

MATERIAL AND METHODS

This prospective observational study was conducted on 185 patients with aneurysmal subarachnoid hemorrhage undergoing clipping of the aneurysmal neck. In our study, blood transfusion was administered to keep the target Hb around 10 g/dL.

RESULTS

Unfavorable long-term outcome was found in 27/97 (28%) of patients who received a blood transfusion as compared to 13/74 (18%) of patients who did not receive a transfusion (P = 0.116). Patients receiving transfusion had more chances of an unfavorable outcome at discharge/7 days as compared to those not transfused [44/103 (43%) versus 22/80 (27%)], P = 0.025. There were increased chances of vasospasm, infarction, re-exploration, tracheostomy, and increased length of hospital stay in patients receiving transfusion (P < 0.05).

CONCLUSIONS

The use of blood transfusion in patients with aneurysmal subarachnoid hemorrhage was associated with increased neurological complications and hence an unfavorable short-term outcome. However, when used judiciously as per the clinical requirements, blood transfusion did not have a significant effect on long-term neurological outcome.

Finite element modeling of shape memory polyurethane foams for treatment of cerebral aneurysms

In this paper, a thermo-mechanical analysis of shape memory polyurethane foams (SMPUFs) with aiding of a finite element model (FEM) for treating cerebral aneurysms (CAs) is introduced. Since the deformation of foam cells is extremely difficult to observe experimentally due to their small size, a structural cell-assembly model is established in this work via finite element modeling to examine all-level deformation details. Representative volume elements of random equilateral Kelvin open-cell microstructures are adopted for the cell foam. Also, a user-defined material subroutine (UMAT) is developed based on a thermo-visco-elastic constitutive model for SMPUFs, and implemented in the ABAQUS software package. The model is able to capture thermo-mechanical responses of SMPUFs for a full shape memory thermodynamic cycle. One of the latest treatments of CAs is filling the inside of aneurysms with SMPUFs. The developed FEM is conducted on patient-specific basilar aneurysms treated by SMPUFs. Three sizes of foams are selected for the filling inside of the aneurysm and then governing boundary conditions and loadings are applied to the foams. The results of the distribution of stress and displacement in the absence and presence of the foam are compared. Due to the absence of similar results in the specialized literature, this paper is likely to fill a gap in the state of the art of this problem and provide pertinent results that are instrumental in the design of SMPUFs for treating CAs.

An early neuroprotective effect of atorvastatin against subarachnoid hemorrhage

Atorvastatin has been shown to reduce early brain edema and neuronal death after subarachnoid hemorrhage, but its mechanism is not clear. In this study, rat models of subarachnoid hemorrhage were established by autologous blood injection in the cisterna magna. Rat models were intragastrically administered 20 mg/kg atorvastatin 24 hours before subarachnoid hemorrhage, 12 and 36 hours after subarachnoid hemorrhage. Compared with the controls, atorvastatin treatment demonstrated that at 72 hours after subarachnoid hemorrhage, neurological function had clearly improved; brain edema was remarkably relieved; cell apoptosis was markedly reduced in the cerebral cortex of rats; the number of autophagy-related protein Beclin-1-positive cells and the expression levels of Beclin-1 and LC3 were increased compared with subarachnoid hemorrhage only. The ultrastructural damage of neurons in the temporal lobe was also noticeably alleviated. The similarities between the effects of atorvastatin and rapamycin were seen in all the measured outcomes of subarachnoid hemorrhage. However, these were contrary to the results of 3-methyladenine injection, which inhibits the signaling pathway of autophagy. These findings indicate that atorvastatin plays an early neuroprotective role in subarachnoid hemorrhage by activating autophagy. The experimental protocol was approved by the Animal Ethics Committee of Anhui Medical University, China (904 Hospital of Joint Logistic Support Force of PLA; approval No. YXLL-2017-09) on February 22, 2017.

Epidemiologic and Evolutionary Profile of Patients With Subarachnoid Hemorrhage With Glasgow Coma Scale Score of 8 or Less Who Entered the Follow-Up Program of the National Institute of Donation and Transplantation

INTRODUCTION

The improvement in understanding the process that determines the death of an individual and his or her evolution toward brain death allows organization and planning of health policies, optimization of clinical activity and management of organ and tissue procurement processes for transplantation.

OBJECTIVE

This study sought to analyze the epidemiological and evolutionary profile of patients with spontaneous subarachnoid hemorrhage (SAH) with a Glasgow Coma Scale score (GCS) ≤8 who entered follow-up in the Neurocritical Patient Monitoring Program (SPN) of Instituto Nacional de Donación y Trasplante (INDT), Uruguay.

MATERIALS AND METHODS

SPN, a monitoring and follow-up program for neurocritical patients with GCS ≤ 8, prospectively collected data from 5 public and private intensive care units. A total of 160 patients with SAH with GCS ≤8 in 10 years were identified and analyzed using a 2-step nested model. Firstly, independent risk factors for mortality were identified, tested in different combinations, and one of them was selected using the best correct classification rate. In the second step, risk factors for evolution to brain death were investigated.

RESULTS

The mortality of patients with SAH with GCS ≤8 was 68%. Mortality for GCS 3 was 82%, significantly higher than for other values on the scale (P = .0025). Female sex (P = .011) and arterial hypertension (P = .017) were associated with higher mortality. There was no significant association between mortality and age, Acute Physiology and Chronic Health Evaluation score, and Simplified Acute Physiologic Score II. Administration of analgesia and/or sedation was a protective factor (P < .0001). Of the patients who died, 50% were in brain death. We did not find clinical elements capable of identifying an increased probability of developing brain death.

CONCLUSIONS

Based on epidemiological data, models capable of improving the understanding of the complex process of death and particularly brain death can be generated. More studies are needed to explore the differential evolutionary behavior of critical neurological illness.

Mild hypothermia protects against early brain injury in rats following subarachnoid hemorrhage via the TrkB/ERK/CREB signaling pathway

Subarachnoid hemorrhage (SAH) is a severe neurological disease, which is associated with a significant number of cases of premature mortality and disability worldwide. Mild hypothermia (MH) has been proposed as a potential therapeutic strategy to reduce neuronal injury following SAH. The present study aimed to investigate the mechanisms of MH's protective role in the process of SAH. The present study demonstrated that MH was able to protect against early brain injury in a rat model of SAH. Treating SAH rats with MH reduced the release of reactive oxygen species and prevented activation of apoptotic cascades. Furthermore, the protective effects of MH were shown to be mediated by enhanced activity of the tropomyosin receptor kinase B/extracellular signal‑regulated kinases/cAMP response element binding protein (TrkB/ERK/CREB) pathway. Inhibition of TrkB/ERK/CREB activity using a small molecule inhibitor largely abolished the beneficial effects of MH in SAH rats. These results outline an endogenous mechanism underlying the neuroprotective effects of MH in SAH.

Early events after aneurysmal subarachnoid hemorrhage

The first 72 h after aneurysmal subarachnoid hemorrhage (SAH) is a critical period for the patient. Most of the deaths in the SAH patient population occur during this time, and a number of key events activate and trigger mechanisms that not only contribute to early brain injury but evolve over time and participate in the delayed complications. This review highlights the contribution of key events to the early brain injury and to overall outcome after SAH.

Mechanisms of acute brain injury after subarachnoid hemorrhage

Brain injury after subarachnoid hemorrhage (SAH) is a biphasic event with an acute ischemic insult at the time of the initial bleed and secondary events such as cerebral vasospasm 3 to 7 days later. Although much has been learned about the delayed effects of SAH, less is known about the mechanisms of acute SAH-induced injury. Distribution of blood in the subarachnoid space, elevation of intracranial pressure, reduced cerebral perfusion and cerebral blood flow (CBF) initiates the acute injury cascade. Together they lead to direct microvascular injury, plugging of vessels and release of vasoactive substances by platelet aggregates, alterations in the nitric oxide (NO)/nitric oxide synthase (NOS) pathways and lipid peroxidation. This review will summarize some of these mechanisms that contribute to acute cerebral injury after SAH.

The importance of early brain injury after subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a medical emergency that accounts for 5% of all stroke cases. Individuals affected are typically in the prime of their lives (mean age 50 years). Approximately 12% of patients die before receiving medical attention, 33% within 48 h and 50% within 30 days of aSAH. Of the survivors 50% suffer from permanent disability with an estimated lifetime cost more than double that of an ischemic stroke. Traditionally, spasm that develops in large cerebral arteries 3-7 days after aneurysm rupture is considered the most important determinant of brain injury and outcome after aSAH. However, recent studies show that prevention of delayed vasospasm does not improve outcome in aSAH patients. This finding has finally brought in focus the influence of early brain injury on outcome of aSAH. A substantial amount of evidence indicates that brain injury begins at the aneurysm rupture, evolves with time and plays an important role in patients' outcome. In this manuscript we review early brain injury after aSAH. Due to the early nature, most of the information on this injury comes from animals and few only from autopsy of patients who died within days after aSAH. Consequently, we began with a review of animal models of early brain injury, next we review the mechanisms of brain injury according to the sequence of their temporal appearance and finally we discuss the failure of clinical translation of therapies successful in animal models of aSAH.

Mild hypothermia (33 degrees C) reduces intracranial hypertension and improves functional outcome after subarachnoid hemorrhage in rats

OBJECTIVE

After a subarachnoid hemorrhage (SAH), the primary cause of mortality is secondary brain injury occurring within the first 48 hours after the initial bleeding. Because of the unknown pathophysiology of these early events, therapeutic approaches are scarce. Because mild hypothermia (33 degrees C) is among the strongest neuroprotectants known so far, the aim of this study was to investigate acute and delayed effects of hypothermia if applied after SAH.

METHODS

Male Sprague-Dawley rats were subjected to SAH and randomly assigned to the following groups: 1) SAH under normothermia, 2) SAH followed by 2 hours of hypothermia starting 1 hour after the bleeding, and 3) SAH followed by 2 hours of hypothermia starting 3 hours after the bleeding. Cerebral blood flow and intracranial pressure were continuously measured up to 6 hours after SAH. Mortality, neurological deficits, and body weight were assessed from postoperative day 1 to day 7. Brain water content and morphological brain damage were quantified 24 hours and 7 days after SAH, respectively.

RESULTS

Mild hypothermia reduced intracranial pressure (P < 0.001) and posthemorrhagic neurological deficits (P < 0.05) and improved postoperative weight gain significantly (P < 0.05). Mortality, cerebral blood flow, and the formation of cerebral edema were not significantly influenced by mild hypothermia.

CONCLUSION

The current results show that mild hypothermia (33 degrees C) exhibits sustained neuroprotection if applied up to 3 hours after SAH. Overall, mild hypothermia seems to be an effective neuroprotective strategy after SAH and should therefore be evaluated as a treatment option for SAH in patients.

Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for the implementation of guidelines and their use in high-risk populations.