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Peng C, Zhao Y, Li F, Guo TZ, Wang XD, Wang BY, Li J, Zhang HR, Yang YF, Liu QG, Ren XL, Yang XY. Aneurysmal Subarachnoid Hemorrhage and Sex Differences: Analysis of Epidemiology, Outcomes, and Risk Factors. Neurocrit Care 2024; 41:119-128. [PMID: 38253923 DOI: 10.1007/s12028-023-01929-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND The differences in outcomes after aneurysmal subarachnoid hemorrhage (aSAH) between the sexes have not been concretely determined. This study aimed to evaluate the differences in epidemiology, outcomes, and risk factors between male and female patients with aSAH. METHODS We performed a multicenter, retrospective study of patients with aSAH from 2017 to 2020. We investigated the epidemiological differences between the two sexes. Propensity score matching (PSM) was used to compare short-term outcomes between the sexes. Binary logarithmic regression was performed to investigate the odds ratio (OR) for dependent survival in patients of different sexes. RESULTS A total of 5,407 consecutive patients with aSAH were included in this study, and the female-to-male ratio was 1.8:1. The peak incidence of aSAH occurred in the 6th and 7th decades in males and females, respectively. There were more female patients with internal carotid artery or posterior communicating artery aneurysms (53.2%), and there were more male patients with anterior cerebral artery or anterior communicating artery aneurysms (43.2%). The incidence of multiple aneurysms was greater in female patients (21.5% vs. 14.2%, P < 0.001). There was no significant difference in outcomes before and after PSM at discharge. The dependent survival risk was related only to the clinical condition on admission in women. In addition, age > 50 years (OR 1.88, 95% confidence interval 1.17-3.02; P = 0.01) and hypertension (OR 1.81, 95% confidence interval 1.25-2.61; P = 0.002) were also risk factors for male patients. CONCLUSIONS There were more female patients with aneurysms than male patients in this study. Most aneurysm locations were different between the two groups. There was no significant difference in discharge outcomes before and after PSM. The risk factors for dependent survival were different between female and male patients.
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Affiliation(s)
- Chao Peng
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Yan Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Fan Li
- Department of Neurosurgery, Heji Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi Province, People's Republic of China
| | - Tie-Zhu Guo
- Department of Neurosurgery, Heji Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi Province, People's Republic of China
| | - Xiang-Dong Wang
- Department of Neurosurgery, Heji Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi Province, People's Republic of China
| | - Bang-Yue Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Jian Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Heng-Rui Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Yi-Fan Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Qing-Guo Liu
- Department of Neurosurgery, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi Province, People's Republic of China
| | - Xin-Liang Ren
- Department of Neurosurgery, Heji Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi Province, People's Republic of China
| | - Xin-Yu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China.
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2
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Sturiale CL, Auricchio AM, Skrap B, Stifano V, Albanese A. The clinical challenge of subarachnoid hemorrhage associated with multiple aneurysms when the bleeding source is not certainly identifiable. J Neurosurg Sci 2024; 68:301-309. [PMID: 34763396 DOI: 10.23736/s0390-5616.21.05609-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Multiple intracranial aneurysms (IAs) are encountered in 20-30% of the subarachnoid hemorrhages (SAH). Neuroimaging and clinical examination are usually sufficient to detect the bleeding source, but sometimes it can be misdiagnosed with catastrophic consequences. METHODS We reviewed our diagnostic work-up for all patients admitted from January 2016 to December 2020 for SAH with multiple IAs accounting for our rate of diagnostic failure. Then, we grouped the patients into 4 categories according to aneurysms topography and described our operative protocol in case of uncertain bleeding origin. RESULTS Sixty-two patients harboring 161 IAs were included. The bleeding source was identified in 56 patients (90.3%), who harbored other 81 bystander aneurysms. In 6 cases (9.7%) with a total of 24 aneurysms we failed the bleeding source identification. According to IAs topography, we grouped the IAs multiplicity in: 1) anterior plus posterior circulation IAs; 2) multiple posterior circulation IAs; 3) bilateral anterior circulation IAs; and 4) multiple ipsilateral anterior circulation IAs. In case of unidentified bleeding source, key-elements favoring the simultaneous multiple IAs treatment were their number, morphology, topography, clinicians' experience, and management modality as endovascular treatment allows a faster exclusion of multiple IAs distant one each other compared with surgery. MCA involvement represented the more frequent reason to prefer multiple clipping rather than multiple coiling. CONCLUSIONS In a small percentage of patients with SAH with multiple IAs, bleeding source identification can be difficult. Until the routinely availability of new tools such as vessel wall imaging or computational fluid dynamics, an experienced neurovascular team and strategies aiming to simultaneously exclude multiple IAs remain mandatory.
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Affiliation(s)
- Carmelo L Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy -
| | - Anna M Auricchio
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Benjamin Skrap
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vito Stifano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessio Albanese
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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3
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Merkel H, Lindner D, Gaber K, Ziganshyna S, Jentzsch J, Mucha S, Gerhards T, Sari S, Stock A, Vothel F, Falter L, Quäschling U, Hoffmann KT, Meixensberger J, Halama D, Richter C. Standardized Classification of Cerebral Vasospasm after Subarachnoid Hemorrhage by Digital Subtraction Angiography. J Clin Med 2022; 11:jcm11072011. [PMID: 35407619 PMCID: PMC9000178 DOI: 10.3390/jcm11072011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 02/05/2023] Open
Abstract
Background: During the last decade, cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) was a current research focus without a standardized classification in digital subtraction angiography (DSA). This study was performed to investigate a device-independent visual cerebral vasospasm classification for endovascular treatment. Methods: The analyses are DSA based rather than multimodal. Ten defined points of intracranial arteries were measured in 45 patients suffering from cerebral vasospasm after SAH at three time points (hospitalization, before spasmolysis, control after six months). Mathematical clustering of vessel diameters was performed to generate four objective grades for comparison. Six interventional neuroradiologists in two groups scored 237 DSAs after a new visual classification (grade 0–3) developed on a segmental pattern of vessel contraction. For the second group, a threshold-based criterion was amended. Results: The raters had a reproducibility of 68.4% in the first group and 75.2% in the second group. The complementary threshold-based criterion increased the reproducibility by about 6.8%, while the rating deviated more from the mathematical clustering in all grades. Conclusions: The proposed visual classification scheme of cerebral vasospasm is suitable as a standard grading procedure for endovascular treatment. There is no advantage of a threshold-based criterion that compensates for the effort involved. Automated vessel analysis is superior to compare inter-group results in research settings.
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Affiliation(s)
- Helena Merkel
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Dirk Lindner
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Khaled Gaber
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Svitlana Ziganshyna
- Department of Anaesthesiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany;
| | - Jennifer Jentzsch
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Simone Mucha
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Thilo Gerhards
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Sabine Sari
- Department of Neuroradiology, Giessen University Hospital, Klinikstraße 33, 35392 Giessen, Germany;
| | - Annika Stock
- Department of Neuroradiology, Würzburg University Hospital, Josef-Schneider-Straße 2, 97080 Würzburg, Germany;
| | - Felicitas Vothel
- Department of Radiology and Neuroradiology, Sana Hospital Borna, Rudolf-Virchow-Straße 2, 04552 Borna, Germany;
| | - Lea Falter
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Ulf Quäschling
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Karl-Titus Hoffmann
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Jürgen Meixensberger
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Dirk Halama
- Department of Oral and Maxillofacial Surgery, Leipzig University Hospital, Liebigstraße 12, 04103 Leipzig, Germany;
| | - Cindy Richter
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
- Correspondence: ; Tel.: +49-341-97-20196
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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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Yu Y, Li Y, Jin Z, Zhao S, Xie X, Chen F. Nimodipine reduces delayed cerebral vasospasm after intracranial tumour surgery: A Retrospective Study. Clin Exp Pharmacol Physiol 2021; 48:1613-1620. [PMID: 34343357 DOI: 10.1111/1440-1681.13564] [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: 01/06/2021] [Revised: 07/18/2021] [Accepted: 07/29/2021] [Indexed: 11/28/2022]
Abstract
Cerebral vasospasm (CVS) is a frequent and serious neurosurgical complication, without sufficient therapy. This retrospective study was performed to analyze if nimodipine can improve prognosis and reduce ischaemia secondary to delayed CVS after intracranial tumour surgery. A retrospective review was performed over the years 2011 to 2012 for patients with an anterior cranial fossa tumour and underwent intracranial tumour surgery. The surgical field was soaked with nimodipine solution or normal saline. Transcranial Doppler ultrasonography was used to measure velocity in the middle cerebral artery (MCA) and the distal extracranial internal carotid artery (eICA). Follow-up was performed using the Glasgow Outcome Scale (GOS) after discharge. There were 94 patients that met the inclusion criteria. They included 50 males and 44 females, with a mean age of 49.6 years. In the nimodipine group, CVS occurred in 13 patients; 9 patients had CVS between 4 and 7 days, and 4 had CVS between 8 and 14 days. In the normal saline group, 19 patients had CVS, 3 presented with CVS within 3 days, 11 between 4-7 days and 5 between 8-14 days. A significant difference in the occurrence of CVS was observed between the two groups. Preoperative and postoperative the MCA velocities were compared, revealing a significant change in the normal saline group but not in the nimodipine group. Nimodipine markedly improves prognosis and significantly reduces ischaemia secondary to delayed CVS after intracranial tumour surgery, as well as the risks of mortality and morbidity.
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Affiliation(s)
- Ying Yu
- Department of Neurosurgery, First Hospital of Jilin University, Jilin, China
| | - Yunqian Li
- Department of Neurosurgery, First Hospital of Jilin University, Jilin, China
| | - Zheng Jin
- Department of Neurosurgery, First Hospital of Jilin University, Jilin, China
| | - Shuai Zhao
- Department of Anesthesiology, First Hospital of Jilin University, Jilin, China
| | - Xuan Xie
- Faculty of Fisheries and Protection of Waters, South Bohemian Research Centre of Aquaculture and Biodiversity of Hydrocenoses, University of South Bohemia in Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Fan Chen
- Department of Neurosurgery, First Hospital of Jilin University, Jilin, China
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6
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Roelz R, Schubach F, Coenen VA, Jenkner C, Scheiwe C, Grauvogel J, Niesen WD, Urbach H, Taschner C, Seufert J, Kätzler J, Beck J, Reinacher PC. Stereotactic cisternal lavage in patients with aneurysmal subarachnoid hemorrhage with urokinase and nimodipine for the prevention of secondary brain injury (SPLASH): study protocol for a randomized controlled trial. Trials 2021; 22:285. [PMID: 33858493 PMCID: PMC8048077 DOI: 10.1186/s13063-021-05208-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed cerebral infarction (DCI) is a major cause of death and poor neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Direct intrathecal therapies with fibrinolytic and spasmolytic drugs have appeared promising in clinical trials. However, access to the subarachnoid space for intrathecal drug administration is an unsolved problem so far, especially in patients with endovascular aneurysm securing. We investigate a therapy protocol based on stereotactic catheter ventriculocisternostomy (STX-VCS), a new approach to overcome this problem. The primary objective of this study is to assess whether cisternal lavage with urokinase, nimodipine, and Ringer's solution administered via a stereotactically implanted catheter into the basal cisterns (= investigational treatment (IT)) is safe and improves neurological outcome in patients with aSAH. METHODS This is a randomized, controlled, parallel-group, open-label phase II trial. Fifty-four patients with severe aSAH (WFNS grade ≥ 3) will be enrolled at one academic tertiary care center in Southern Germany. Patients will be randomized at a ratio of 1:1 to receive either standard of care only or standard of care plus the IT. The primary endpoint is the proportion of subjects with a favorable outcome on the Modified Rankin Scale (defined as mRS 0-3) at 6 months after aSAH. Further clinical and surrogate outcome parameters are defined as secondary endpoints. DISCUSSION New approaches for the prevention and therapy of secondary brain injury in patients with aSAH are urgently needed. We propose this RCT to assess the clinical safety and efficacy of a novel therapy protocol for intrathecal administration of urokinase, nimodipine, and Ringer's solution. TRIAL REGISTRATION Deutsches Register Klinischer Studien (German Clinical Trials Register), DRKS00015645 . Registered on 8 May 2019.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Fabian Schubach
- Clinical Trials Unit, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Carolin Jenkner
- Clinical Trials Unit, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Taschner
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jochen Seufert
- Department of Medicine II, Division of Endocrinology and Diabetology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Kätzler
- Department of Internal Medicine III, Clinical Trials Office, University Medical Center Ulm, Ulm, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
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7
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Hostettler IC, Sebök M, Ambler G, Muroi C, Prömmel P, Neidert MC, Richter JK, Pangalu A, Regli L, Germans MR. Validation and Optimization of Barrow Neurological Institute Score in Prediction of Adverse Events and Functional Outcome After Subarachnoid Hemorrhage-Creation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score. Neurosurgery 2021; 88:96-105. [PMID: 32779716 DOI: 10.1093/neuros/nyaa316] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/24/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Barrow Neurological Institute (BNI) score, measuring maximal thickness of aneurysmal subarachnoid hemorrhage (aSAH), has previously shown to predict symptomatic cerebral vasospasms (CVSs), delayed cerebral ischemia (DCI), and functional outcome. OBJECTIVE To validate the BNI score for prediction of above-mentioned variables and cerebral infarct and evaluate its improvement by integrating further variables which are available within the first 24 h after hemorrhage. METHODS We included patients from a single center. The BNI score for prediction of CVS, DCI, infarct, and functional outcome was validated in our cohort using measurements of calibration and discrimination (area under the curve [AUC]). We improved it by adding additional variables, creating a novel risk score (measure by the dichotomized Glasgow Outcome Scale) and validated it in a small independent cohort. RESULTS Of 646 patients, 41.5% developed symptomatic CVS, 22.9% DCI, 23.5% cerebral infarct, and 29% had an unfavorable outcome. The BNI score was associated with all outcome measurements. We improved functional outcome prediction accuracy by including age, BNI score, World Federation of Neurologic Surgeons, rebleeding, clipping, and hydrocephalus (AUC 0.84, 95% CI 0.8-0.87). Based on this model we created a risk score (HATCH-Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus), ranging 0 to 13 points. We validated it in a small independent cohort. The validated score demonstrated very good discriminative ability (AUC 0.84 [95% CI 0.72-0.96]). CONCLUSION We developed the HATCH score, which is a moderate predictor of DCI, but excellent predictor of functional outcome at 1 yr after aSAH.
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Affiliation(s)
- Isabel Charlotte Hostettler
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Stroke Research Centre, University College London, Institute of Neurology, London, United Kingdom.,Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Martina Sebök
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Clinical Neuroscience Center Zurich, Zurich, Switzerland
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - Carl Muroi
- Neurocritical Care Unit, Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Peter Prömmel
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Johannes Konstantin Richter
- Department of Neuroradiology, University Hospital, University of Zurich, Zurich, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology (DIPR), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Athina Pangalu
- Department of Neuroradiology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Clinical Neuroscience Center Zurich, Zurich, Switzerland
| | - Menno Robbert Germans
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Clinical Neuroscience Center Zurich, Zurich, Switzerland
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Marbacher S, Bircher B, Vogt DR, Diepers M, Remonda L, Fandino J. Periinterventional Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage Predicts an Unfavorable Clinical Course. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okaa021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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9
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Jabbarli R, Darkwah Oppong M, Roelz R, Pierscianek D, Shah M, Dammann P, Scheiwe C, Kaier K, Wrede KH, Beck J, Sure U. The PRESSURE score to predict decompressive craniectomy after aneurysmal subarachnoid haemorrhage. Brain Commun 2020; 2:fcaa134. [PMID: 33215084 PMCID: PMC7660044 DOI: 10.1093/braincomms/fcaa134] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 12/14/2022] Open
Abstract
The prognosis of patients with aneurysmal subarachnoid haemorrhage requiring decompressive craniectomy is usually poor. Proper selection and early performing of decompressive craniectomy might improve the patients’ outcome. We aimed at developing a risk score for prediction of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. All consecutive aneurysmal subarachnoid haemorrhage cases treated at the University Hospital of Essen between January 2003 and June 2016 (test cohort) and the University Medical Center Freiburg between January 2005 and December 2012 (validation cohort) were eligible for this study. Various parameters collected within 72 h after aneurysmal subarachnoid haemorrhage were evaluated through univariate and multivariate analyses to predict separately primary (PrimDC) and secondary decompressive craniectomy (SecDC). The final analysis included 1376 patients. The constructed risk score included the following parameters: intracerebral (‘Parenchymal’) haemorrhage (1 point), ‘Rapid’ vasospasm on angiography (1 point), Early cerebral infarction (1 point), aneurysm Sac > 5 mm (1 point), clipping (‘Surgery’, 1 point), age Under 55 years (2 points), Hunt and Hess grade ≥ 4 (‘Reduced consciousness’, 1 point) and External ventricular drain (1 point). The PRESSURE score (0–9 points) showed high diagnostic accuracy for the prediction of PrimDC and SecDC in the test (area under the curve = 0.842/0.818) and validation cohorts (area under the curve = 0.903/0.823), respectively. 63.7% of the patients scoring ≥6 points required decompressive craniectomy (versus 12% for the PRESSURE < 6 points, P < 0.0001). In the subgroup of the patients with the PRESSURE ≥6 points and absence of dilated/fixed pupils, PrimDC within 24 h after aneurysmal subarachnoid haemorrhage was independently associated with lower risk of unfavourable outcome (modified Rankin Scale >3 at 6 months) than in individuals with later or no decompressive craniectomy (P < 0.0001). Our risk score was successfully validated as reliable predictor of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. The PRESSURE score might present a background for a prospective randomized clinical trial addressing the utility of early prophylactic decompressive craniectomy in aneurysmal subarachnoid haemorrhage.
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Affiliation(s)
- Ramazan Jabbarli
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
| | | | - Roland Roelz
- Department of Neurosurgery, Medical Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
| | - Mukesch Shah
- Department of Neurosurgery, Medical Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg Institute for Medical Biometry and Medical Informatics, University Medical Center Freiburg, D-79106 Freiburg, Germany
| | - Karsten H Wrede
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
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Darkwah Oppong M, Gembruch O, Pierscianek D, Köhrmann M, Kleinschnitz C, Deuschl C, Mönninghoff C, Kaier K, Forsting M, Sure U, Jabbarli R. Post-treatment Antiplatelet Therapy Reduces Risk for Delayed Cerebral Ischemia due to Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2020; 85:827-833. [PMID: 30544176 DOI: 10.1093/neuros/nyy550] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 10/24/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) has a strong impact on outcome of patients with aneurysmal subarachnoid hemorrhage (SAH). Positive effect of antiplatelet therapy on DCI rates has been supposed upon smaller SAH series. OBJECTIVE To analyze the benefit/risk profile of antiplatelet use in SAH patients. METHODS This retrospective case-control study was based on institutional observational cohort with 994 SAH patients treated between January 2003 and June 2016. The individuals with postcoiling antiplatelet therapy (aspirin with/without clopidogrel) were compared to a control group without antiplatelet therapy. Occurrence of DCI, major/minor bleeding events in the follow-up computed tomography scans, and favorable outcome at 6 mo after SAH (modified Rankin scale < 3) were compared in both groups. RESULTS Of 580 patients in the final analysis, 329 patients received post-treatment antiplatelet medication. There were no significant differences between the compared groups with regard to basic outcome confounders. Aspirin use was independently associated with reduced DCI risk (P < .001, adjusted odds ratio = 0.41, 95% confidence interval 0.24-0.65) and favorable outcome (P = .02, adjusted odds ratio = 1.78, 95% confidence interval 1.06-2.98). Regarding bleeding complications, aspirin was associated only with minor bleeding events (P = .02 vs P = .51 for major bleeding events). CONCLUSION Regular administration of aspirin might have a positive impact on DCI risk and outcome of SAH patients, without increasing the risk for clinically relevant bleeding events. In our SAH cohort, dual antiplatelet therapy showed no additional benefit on DCI risk, but increased the likelihood of major bleeding events.
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Affiliation(s)
- Marvin Darkwah Oppong
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Oliver Gembruch
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | | | | | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Christoph Mönninghoff
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
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11
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Tabaie A, Nemati S, Allen JW, Chung C, Queiroga F, Kuk WJ, Prater AB. Assessing Contribution of Higher Order Clinical Risk Factors to Prediction of Outcome in Aneurysmal Subarachnoid Hemorrhage Patients. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2020; 2019:848-856. [PMID: 32308881 PMCID: PMC7153066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The goal of this study was to investigate the application of machine learning models capable of capturing multiplica tive and temporal clinical risk factors for outcome prediction inpatients with aneurysmal subarachnoid hemorrhage (aSAH). We examined a cohort of 575 aSAH patients from Emory Healthcare, identified via digital subtraction angiog- raphy. The outcome measure was the modified Ranking Scale (mRS) after 90 days. Predictions were performed with longitudinal clinical and imaging risk factors as inputs into a regularized Logistic Regression, a feedforward Neural Network and a multivariate time-series prediction model known as the long short-term memory (LSTM) architecture. Through extraction of higher-order risk factors, the LSTM model achieved an AUC of 0.89 eight days into hospitaliza tion, outperforming other techniques. Our preliminary findings indicate the proposed model has the potential to aid treatment decisions and effective imaging resource utilization in high-risk patients by providing actionable predictions prior to the development of neurological deterioration.
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Affiliation(s)
- Azade Tabaie
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA
| | - Shamim Nemati
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA
| | - Jason W Allen
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA
| | - Charlotte Chung
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA
| | - Flavia Queiroga
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA
| | - Won-Jun Kuk
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA
| | - Adam B Prater
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA
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12
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Zou W, Deng Y, Chen G, Shangguan S, Zhou F, Jiang W, Li X. Influence of butyphthalide combined with urinary kallikrein in ACI treatment on neuro-cytokines and vascular endothelial function and its clinical effect. Int J Neurosci 2020; 131:25-30. [PMID: 32075474 DOI: 10.1080/00207454.2020.1732972] [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: 10/25/2022]
Abstract
Objective: To study the influence of butyphthalide combined with urinary kallikrein in acute cerebral infarction (ACI) treatment on neuro-cytokines and indicators of vascular endothelial function, observe the curative effect and adverse effects, and discuss its safety and feasibility.Method: 110 ACI patients were chosen as the objects, and classified into observation group (55 cases) and control group (55 cases) according to the method of random number table. Butyphthalide injection combined with urinary kallikrein was adopted for the observation group based on conventional treatment, while cinepazide maleate injection combined with alprostadil injection was applied for the control group based on conventional treatment. The following indicators of both groups were compared before and after treatment: neurotrophic factor (NTF), nerve growth factor (NGF), neuron specific enolase (NSE); content of CXC chemotactic factor ligand 16 (CXCL16), soluble CD ligand (CD40L), Fibulin-5 and high mobility group box B1 (HMGB1); the content of indicators of vascular endothelial function including plasma endothelin -1 (ET-1) and no therapeutic effects and adverse effects were recorded.Results: NSE of both groups after treatment decreased obviously, and the content of NTF and NGF increased obviously. NSE content of observation group was lower than that of control group. NTF content and NGF content of observation group were higher than those of control group. The differences had statistical significance (p < 0.05). The levels of CXCL16, CD40L, Fibulin-5 and HMGB1 declined obviously, compared with pre-treatment, and the levels of observation groups were significantly lower than those of control grip. The differences had statistical significance (p < 0.05). ET-1 level rose significantly after treatment, and NO level declined obviously after treatment. ET-1 level of observation group was significantly higher than that of control group, and NO level of observation group was significantly lower than that of control group. The difference had statistical significance (p < 0.05). Clinical effect of observation group was significantly higher than that of control group. The difference had statistical significance (p < 0.05). The comparison difference of both groups in the occurrence rate of adverse effects had no statistical significance (p > 0.05).Conclusion: The application of butyphthalide combined with urinary kallikrein in ACI treatment can effectively inhibit secretion and release of neuro-cytokines, and improve patients' vascular endothelial function, with significant treatment effect and high safety. Therefore, it deserves to be promoted clinically.
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Affiliation(s)
- Wenqin Zou
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Yanqing Deng
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Guanghui Chen
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Shouqin Shangguan
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Faming Zhou
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Wenxin Jiang
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Xiaoli Li
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
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13
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Roelz R, Scheiwe C, Urbach H, Coenen VA, Reinacher P. Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage in Patients with Coiled Aneurysms. Oper Neurosurg (Hagerstown) 2019; 14:231-235. [PMID: 28582545 DOI: 10.1093/ons/opx129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 05/01/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Current treatments of cerebral vasospasm are insufficient. Cisternal blood clearance is a promising treatment option. However, a generally applicable, safe, and effective method to access the cisterns of the brain is lacking. OBJECTIVE To report on stereotactic catheter ventriculocisternostomy (STX-VCS) as a method to access the cisterns of the brain for clearance of subarachnoid hemorrhage in patients with aSAH and coiled aneurysms. METHODS In 9 aSAH patients at high risk for DCI (Hunt and Hess grade ≥3, modified Fisher grade ≥3), access to the basal cisterns of the brain was created by STX-VCS. Fibrinolytic and/or spasmolytic lavage therapy was administered. RESULTS STX-VCS was feasible and safe in all patients. Subarachnoid blood was rapidly cleared by irrigation with urokinase. Vasospasm occurred in 2 patients and was interrupted by irrigation with nimodipine. There was 1 fatality due to pneumogenic sepsis. Minor DCI occurred in 1 patient. Eight survived without DCI and are independent (modified Rankin score [mRS] ≤ 3) at 6 mo after aSAH. CONCLUSION STX-VCS allows for rapid clearance of subarachnoid hemorrhage in patients with coiled aneurysms.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradio-logy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurg-ery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Peter Reinacher
- Department of Stereotactic and Functional Neurosurg-ery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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14
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Fang YJ, Mei SH, Lu JN, Chen YK, Chai ZH, Dong X, Araujo C, Reis C, Zhang JM, Chen S. New risk score of the early period after spontaneous subarachnoid hemorrhage: For the prediction of delayed cerebral ischemia. CNS Neurosci Ther 2019; 25:1173-1181. [PMID: 31407513 PMCID: PMC6776741 DOI: 10.1111/cns.13202] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 01/09/2023] Open
Abstract
Background and Purpose The aim of this study is to identify the early predictors for delayed cerebral ischemia (DCI) and develop a risk stratification score by focusing on the early change after aneurysmal subarachnoid hemorrhage (aSAH). Methods The study retrospectively reviewed aSAH patients between 2014 and 2015. Risk factors within 72 hours after aSAH were included into univariable and multivariable logistic regression analysis to screen the independent predictors for DCI and to design a risk stratification score. Results We analyzed 702 aSAH patients; four predictors were retained from the final multivariable analysis: World Federation of Neurosurgical Societies scale (WFNS; OR = 4.057, P < .001), modified Fisher Scale (mFS; OR = 2.623, P < .001), Subarachnoid Hemorrhage Early Brain Edema Score (SEBES; OR = 1.539, P = .036), and intraventricular hemorrhage (IVH; OR = 1.932, P = .002). According to the regression coefficient, we created a risk stratification score ranging from 0 to 7 (WFNS = 3, mFS = 2, SEBES = 1, and IVH = 1). The new score showed a significantly higher area under curve (0.785) compared with other scores (P < .001). Conclusion The early DCI score provides a practical method at the early 72 hours after aSAH to predict DCI.
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Affiliation(s)
- Yuan-Jian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shu-Hao Mei
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jia-Nan Lu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi-Ke Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhao-Hui Chai
- Department of Neurosurgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao Dong
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Camila Araujo
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jian-Min Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Brain Research Institute, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, China
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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15
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Jabbarli R, Pierscianek D, Rölz R, Darkwah Oppong M, Kaier K, Shah M, Taschner C, Mönninghoff C, Urbach H, Beck J, Sure U, Forsting M. Endovascular treatment of cerebral vasospasm after subarachnoid hemorrhage. Neurology 2019; 93:e458-e466. [DOI: 10.1212/wnl.0000000000007862] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/21/2019] [Indexed: 12/20/2022] Open
Abstract
ObjectiveDelayed cerebral ischemia (DCI) is strongly associated with poor outcome after subarachnoid hemorrhage (SAH). Cerebral vasospasm is a major contributor to DCI and requires special attention. To evaluate the effect of vasospasm management on SAH outcome, we performed a pooled analysis of 2 observational SAH cohorts.MaterialsData from 2 institutional databases with consecutive patients with SAH treated between 2005 and 2012 were pooled. The effect of 2 institutional standards of conservative and endovascular vasospasm treatment (EVT) on the rates of DCI (new cerebral infarcts not visible on the post-treatment imaging) and unfavorable outcome (modified Rankin Scale score >2) at 6 months follow-up was analyzed.ResultsThe final analysis included 1,057 patients with SAH. There was no difference regarding demographic (age and sex), clinical (Hunt & Hess grades, acute hydrocephalus, treatment modality, and infections), and radiographic (Fisher grades and aneurysm location) characteristics of the populations. However, there was a significant difference in the rate (24.4% [121/495] vs 14.4% [81/562], p < 0.0001) and timing (first treatment on day 6 vs 8.9 after SAH, p < 0.0001) of EVT. The rates of DCI (20.8% vs 29%, p = 0.0001) and unfavorable outcome (44% vs 50.6%, p = 0.04) were lower in the cohort with more frequent and early EVT. Multivariate analysis confirmed independent effect of EVT standard on DCI risk and outcome.ConclusionsA preventive strategy utilizing frequent and early EVT seems to reduce the risk of DCI in patients with SAH and improve their functional outcome. We recommend prospective evaluation of the value of preventive EVT strategy on SAH.Classification of evidenceThis study provides Class III evidence that for patients with SAH, a frequent and early EVT to treat vasospasm reduces the risk of DCI and improves functional outcome.
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16
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Roelz R, Scheiwe C, Coenen VA, Reinacher PC. A novel rescue therapy for cerebral vasospasm: Cisternal Nimodipine application via stereotactic catheter ventriculocisternostomy. J Clin Neurosci 2019; 63:244-248. [PMID: 30737093 DOI: 10.1016/j.jocn.2019.01.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 01/28/2019] [Indexed: 01/03/2023]
Abstract
Delayed Cerebral Infarction (DCI) due to Cerebral Vasospasm (CVS) is an important contributor to poor outcome after aneurysmal subarachnoid haemorrhage (aSAH). Despite established risk factors CVS and DCI are unpredictable at the individual patient level. Efficient treatments are lacking. We report a novel rescue therapy for DCI: Access to the basal cisterns by stereotactic catheter ventriculocisternostomy (STX-VCS) and direct cisternal application of the spasmolytic agent Nimodipine. On the basis of individual treatment decisions three aSAH patients who developed CVS underwent STX-VCS. Continuous lavage with Nimodipine was performed. CVS was assessed by daily transcranial doppler ultrasonography. Neurological outcome at 3 months was assessed by modified Rankin scale. STX-VCS was performed without complications in all patients. CVS rapidly resolved upon cisternal application of Nimodipine. CVS recurred in two patients upon interruption of Nimodpine application and resolved upon restart of Nimodipine. DCI did not occur in all three cases. STX-VCS and cisternal Nimodipine application is a novel rescue therapy for CVS treatment and DCI-prevention in patients with aSAH.
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Affiliation(s)
- Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany.
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany
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17
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Jabbarli R, Pierscianek D, Darkwah Oppong M, Sato T, Dammann P, Wrede KH, Kaier K, Köhrmann M, Forsting M, Kleinschnitz C, Roos A, Sure U. Laboratory biomarkers of delayed cerebral ischemia after subarachnoid hemorrhage: a systematic review. Neurosurg Rev 2018; 43:825-833. [PMID: 30306357 DOI: 10.1007/s10143-018-1037-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 09/19/2018] [Accepted: 09/21/2018] [Indexed: 01/25/2023]
Abstract
Delayed cerebral ischemia (DCI) is a severe complication of subarachnoid hemorrhage (SAH). Clinical and radiographic features of SAH may be helpful in identification of individuals prone to DCI. The aim of this systematic review was to analyze the present evidence on predictive value of blood and cerebrospinal fluid (CSF) biomarkers of DCI after SAH. We systematically searched in PubMed, Scopus, Web of Science, and Cochrane Library databases for publications before July 15, 2018, reporting correlations between blood/CSF biomarkers and occurrence of DCI and/or vasospasm in SAH patients. Included studies underwent quality assessment according to QUIPS and STARD guidelines. Level of evidence (I-IV) for each of tested biomarkers was assessed according to GRADE guidelines. Of 2181 unique records identified in four databases, 270 original articles and 5 meta-analyses were included to this review. Of 257 blood and CSF parameters analyzed in 16.914 SAH patients, there was no biomarker with positive association with DCI/vasospasm showing level I evidence. Twenty-one biomarkers achieved level II evidence and could be confirmed as predictive biomarkers. In this review, six single nucleotide polymorphisms (for EET metabolic pathways, COMT, HMGB1, ACE, PAI-1 promoter, and Hp genes) and 15 non-genetic biomarkers (pNF-H, ADAMTS13, NPY, Copeptin, HMGB1, GFAP, periostin, Tau, BNP, NT pro-BNP, hs-TnT, PA-TEGMA, MPV:PLT, NLR, and PLR) were selected as predictive DCI biomarkers. We propose that a panel analysis of the selected genetic and protein biomarker candidates would be needed for further validation in a large SAH cohort.
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Affiliation(s)
- Ramazan Jabbarli
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany.
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
| | | | - Tako Sato
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Köhrmann
- Clinic for Neurology, University Hospital of Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital of Essen, Essen, Germany
| | | | - Andreas Roos
- Leibniz Institute for Analytical Sciences - ISAS - e.V., Dortmund, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital of Essen, D-45147, Essen, Germany
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18
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Wei B, Liu Y. Clinical significance and efficacy analysis of atorvastatin in the treatment of patients with cerebral infarction and aspiration pneumonia. Exp Ther Med 2018; 16:5144-5148. [PMID: 30542469 PMCID: PMC6257107 DOI: 10.3892/etm.2018.6829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 09/06/2018] [Indexed: 12/24/2022] Open
Abstract
Therapeutic efficacy of the use of oral atorvastatin in the treatment of patients with aspiration pneumonia complicated with cerebral infarction was investigated. Three hundred and fourteen cerebral infarction patients complicated with aspiration pneumonia who were admitted to the emergency department of Beijing Chaoyang Hospital Jingxi Branch from May 2015 to July 2017 were retrospectively analyzed. Among them, 160 patients who took atorvastatin were treated as observation group, and the remaining 154 patients were the control group. Patients were given basic treatment after diagnosis, and atorvastatin was also used for patients in the observation group. Venous blood was extracted to detect blood lipids and inflammatory cytokines. Patients were followed up for a period of six months, and the mortality was recorded. After treatment, blood lipid function and inflammatory factors in both groups were significantly improved (P<0.05). Hospital stay in the observation group (86.88%) was significantly shorter than that in the control group (76.33%) (P<0.01). After treatment, levels of TC, LDL, TG and CRP in the observation group (86.25%) were significantly lower than those in the control group (76.32%) (P=0.01). However, after treatment, level of HDL-C in the observation group (11.88%) was significantly higher than that in the control group (23.38%) (P=0.01). After treatment, levels of IL-6, IL-8 and TNF-α in the observation group were significantly lower than those in the control group (P<0.01). Total effective rate in the observation group was significantly higher than that of the control group (P=0.01). Total death rate in the observation group was significantly lower than that in the control group (P=0.02). In conclusion, atorvastatin is effective in the treatment of cerebral infarction patients complicated with aspiration pneumonia.
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Affiliation(s)
- Bing Wei
- Department of Emergency Medicine, Beijing Chaoyang Hospital Jingxi Branch, Capital Medical University, Beijing 100043, P.R. China
| | - Yugeng Liu
- Department of Emergency Medicine, Beijing Chaoyang Hospital Jingxi Branch, Capital Medical University, Beijing 100043, P.R. China
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19
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Dinc N, Quick-Weller J, Tritt S, Konczalla J, Mersmann J, Bruder M, Herrmann E, Seifert V, Senft C. Vasospasm of the basilar artery following spontaneous SAH-clinical observations and implications for vascular research. Neurosurg Rev 2018; 42:983-989. [PMID: 30088111 DOI: 10.1007/s10143-018-1015-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/15/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
Abstract
The basilar artery (BA), as a reference vessel for laboratory investigations of cerebral vasospasm (CVS) in many experimental models, warrants a sufficient blood supply despite hemodynamic changes during CVS. In a prospective evaluation study, we analyzed patients who were admitted to our department with subarachnoid hemorrhage (SAH) for the occurrence and sequelae of CVS. Specifically, we sought to identify patients with CVS of the BA. As per institutional protocol, all patients with CVS detected in the posterior circulation had magnetic resonance imaging (MRI) examinations instead of CTA. Between January and December 2016, 74 patients were treated for spontaneous SAH. CVS occurred in 45 (61%) patients, and 31 (42%) patients developed associated cerebral infarctions (CI). CVS was significantly associated with CI (p < 0.0001; OR 44). In 18 (24.3%) patients, CVS significantly affected the basilar artery. Poor admission clinical state, younger age, and treatment modalities were significantly associated with BACVS. BACVS was more often detected in patients with severe CVS (p < 0.046; OR 4.4). Patients with BACVS developed cerebral infarction in a frequency comparable to other patients with CVS (61% vs. 70%, p = 0.7), but none of these infarctions occurred in the brain stem or pons even though vessel diameter was dramatically reduced according to CT- and/or MR-angiography. BACVS does not appear to be followed by cerebral infarction in the BA territory, presumably due to a vascular privilege of this vessel and its perforating branches. In contrast, brain ischemia can frequently be observed in the territories of other major arteries affected by CVS.
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Affiliation(s)
- Nazife Dinc
- Department of Neurosurgery, Goethe University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany.
| | - J Quick-Weller
- Department of Neurosurgery, Goethe University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - S Tritt
- Department of Neuroradiology, Goethe University Hospital, Frankfurt, Germany
| | - J Konczalla
- Department of Neurosurgery, Goethe University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - J Mersmann
- Department of Anesthesiology, Goethe University Hospital, Frankfurt, Germany
| | - M Bruder
- Department of Neurosurgery, Goethe University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - E Herrmann
- Department of Biostatistics and Mathematical Modeling, Goethe University Hospital, Frankfurt, Germany
| | - V Seifert
- Department of Neurosurgery, Goethe University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - C Senft
- Department of Neurosurgery, Goethe University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
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Germans MR, Jaja BNR, de Oliviera Manoel AL, Cohen AH, Macdonald RL. Sex differences in delayed cerebral ischemia after subarachnoid hemorrhage. J Neurosurg 2018; 129:458-464. [DOI: 10.3171/2017.3.jns162808] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVEIn this study the authors sought to investigate the sex differences in the risk of delayed cerebral ischemia (DCI), delayed cerebral infarction, and the role of hormonal status.METHODSTen studies included in the SAHIT (SAH International Trialists) repository were analyzed using a fitting logistic regression model. Heterogeneity between the studies was tested using I2 statistics, and the results were pooled using a random-effects model. Multivariable analysis was adjusted for the effects of neurological status and fixed effect of study. An additional model was examined in which women and men were split into groups according to an age cut point of 55 years, as a surrogate to define hormonal status.RESULTSA pooled cohort of 6713 patients was analyzed. The risk of DCI was statistically significantly higher in women than in men (OR 1.29, 95% CI 1.12–1.48); no difference was found with respect to cerebral infarction (OR 1.17, 95% CI 0.98–1.40). No difference was found in the risk of DCI when comparing women ≤ 55 and > 55 years (OR 0.87, 95% CI 0.74–1.02; p = 0.08) or when comparing men ≤ 55 and > 55 years (p = 0.38). Independent predictors of DCI were World Federation of Neurosurgical Societies (WFNS) grade, Fisher grade, age, and sex. Independent predictors of infarction included WFNS grade, Fisher grade, and aneurysm size.CONCLUSIONSFemale sex is associated with a higher risk of DCI. Sex differences may play a role in the pathogenesis of DCI but are not associated with menopausal status. The predictors of DCI and cerebral infarction were identified in a very large cohort and reflect experience from multiple institutions.
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Affiliation(s)
- Menno R. Germans
- 1Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | - R. Loch Macdonald
- 4Division of Neurosurgery, Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael’s Hospital; and
- 5Faculty of Medicine, University of Toronto, Ontario, Canada
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21
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Foreman B, Albers D, Schmidt JM, Falo CM, Velasquez A, Connolly ES, Claassen J. Intracortical electrophysiological correlates of blood flow after severe SAH: A multimodality monitoring study. J Cereb Blood Flow Metab 2018; 38:506-517. [PMID: 28387139 PMCID: PMC5851141 DOI: 10.1177/0271678x17700433] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a devastating form of stroke. Approximately one in four patients develop progressive neurological deterioration and silent infarction referred to as delayed cerebral ischemia (DCI). DCI is a complex, multifactorial secondary brain injury pattern and its pathogenesis is not fully understood. We aimed to study the relationship between cerebral blood flow (CBF) and neuronal activity at both the cortex and in scalp using electroencephalography (EEG) in poor-grade SAH patients undergoing multimodality intracranial neuromonitoring. Twenty patients were included, of whom half had DCI median 4.7 days (interquartile range (IQR): 4.0-5.6) from SAH bleed. The rate of decline in regional cerebral blood flow (rCBF) was significant in both those with and without DCI and occurred between days 4 and 7 post-SAH. The scalp EEG alpha-delta ratio declined early in those with DCI. In the group without DCI, CBF and cortical EEG alpha-delta ratio were correlated (r = 0.53; p < 0.01) and in the group without DCI, inverse neurovascular coupling was observed at CPP < 80 mmHg. We found preliminary evidence that as patients enter the period of highest risk for the development of DCI, the absence of neurovascular coupling may act as a possible pathomechanism in the development of ischemia following SAH.
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Affiliation(s)
- Brandon Foreman
- 1 Department of Neurology, Columbia University, New York, USA.,2 Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, USA
| | - David Albers
- 3 Department of Biomedical Informatics, Columbia University, New York, USA
| | | | | | | | | | - Jan Claassen
- 1 Department of Neurology, Columbia University, New York, USA.,4 Department of Neurosurgery, Columbia University, New York, USA
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Jabbarli R, Reinhard M, Roelz R, Shah M, Niesen WD, Kaier K, Taschner C, Weyerbrock A, Van Velthoven V. Intracerebral Hematoma Due to Aneurysm Rupture: Are There Risk Factors Beyond Aneurysm Location? Neurosurgery 2017; 78:813-20. [PMID: 26619334 DOI: 10.1227/neu.0000000000001136] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Along with subarachnoid hemorrhage (SAH), a ruptured aneurysm may also cause an intracerebral hematoma (ICH), which negatively impacts the functional outcome of SAH. OBJECTIVE To identify independent risk factors of aneurysmal ICH. METHODS Six hundred thirty-two consecutive patients with aneurysmal SAH treated at our institution from January 2005 to December 2012 were eligible for this study. Demographic parameters and preexisting comorbidities of patients, as well as various clinical and radiographic characteristics of SAH were correlated with the incidence and volume of aneurysmal ICH. RESULTS One hundred fifty-five patients (25%) had ICH on initial computed tomography with a mean volume of 26.7 mL (±26.8 mL). Occurrence and volume of ICH were associated with the location (distal anterior or middle cerebral artery >proximal anterior cerebral or internal carotid artery >posterior circulation, P < .001/P < .001) and size (>12 mm, P = .026/P < .001) of the ruptured aneurysm. Vascular risk factors independently increased the risk of ICH as well (arterial hypertension: odds ratio [OR] = 1.62, P = .032; diabetes mellitus: OR = 3.06, P = .009), while the use of aspirin (P = .037) correlated with the volume of ICH. The predictors of ICH were included into a risk score (0-9 points) that strongly predicted the occurrence of ICH (P = .01). Poor functional outcome after SAH was independently associated with the occurrence of ICH (P = .003, OR = 2.77) and its volume (P = .001, OR = 1.07 per-mL-increase). CONCLUSION Aneurysmal ICH is strongly associated with poorer functional outcome and seems to be predictable even before the bleeding event. The proposed risk factors for aneurysmal ICH require further validation and may be considered for treatment decisions regarding unruptured intracranial aneurysms. ABBREVIATIONS ACA, anterior cerebral arteryDHC, decompressive hemicraniectomyEVD, external ventricular drainageICA, internal carotid arteryICH, intracerebral hematomaMCA, middle cerebral arterymRS, modified Rankin scalePC, posterior circulationSAH, subarachnoid hemorrhageSIRS, systemic inflammatory response syndromeTCD, transcranial Doppler sonography.
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Affiliation(s)
- Ramazan Jabbarli
- *Department of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany; ‡Department of Neurosurgery, University Hospital Essen, Essen, Germany; §Department of Neurology, University Medical Center Freiburg, Freiburg, Germany; ‖Institute for Medical Biometry and Medical Informatics, University Medical Center Freiburg, Freiburg, Germany; ¶Department of Neuroradiology, University Medical Center Freiburg, Freiburg, Germany
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23
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Jabbarli R, Reinhard M, Roelz R, Kaier K, Weyerbrock A, Taschner C, Scheiwe C, Shah M. Clinical relevance of anterior cerebral artery asymmetry in aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 127:1070-1076. [DOI: 10.3171/2016.9.jns161706] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAn asymmetry of the A1 segments (A1SA) of the anterior cerebral arteries (ACAs) is an assumed risk factor for the development of anterior communicating artery aneurysms (ACoAAs). It is unknown whether A1SA is also clinically relevant after aneurysm rupture. The authors of this study investigated the impact of A1SA on the clinical course and outcome of patients with aneurysmal subarachnoid hemorrhage (SAH).METHODSThe authors retrospectively analyzed data on consecutive SAH patients treated at their institution between January 2005 and December 2012. The occurrence and severity of cerebral infarctions in the ACA territories were evaluated on follow-up CT scans up to 6 weeks after SAH. Moreover, the risk for an unfavorable outcome (defined as > 3 points on the modified Rankin Scale) at 6 months after SAH was assessed.RESULTSA total of 594 patients were included in the final analysis. An A1SA was identified on digital subtraction angiography studies from 127 patients (21.4%) and was strongly associated with ACoAA (p < 0.0001, OR 13.7). An A1SA independently correlated with the occurrence of ACA infarction in patients with ACoAA (p = 0.047) and in those without an ACoAA (p = 0.015). Among patients undergoing ACoAA coiling, A1SA was independently associated with the severity of ACA infarction (p = 0.023) and unfavorable functional outcome (p = 0.045, OR = 2.4).CONCLUSIONSAn A1SA is a common anatomical variation in SAH patients and is strongly associated with ACoAA. Moreover, the presence of A1SA independently increases the likelihood of ACA infarction. In SAH patients undergoing ACoAA coiling, A1SA carries the risk for severe ACA infarction and thus an unfavorable outcome.Clinical trial registration no.: DRKS00005486 (http://www.drks.de/)
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Affiliation(s)
- Ramazan Jabbarli
- Departments of 1Neurosurgery,
- 2Department of Neurosurgery, University Hospital Essen; and
| | - Matthias Reinhard
- 3Department of Neurology and Clinical Neurophysiology, Klinikum Esslingen, Germany
- 4Neurology and Neurophysiology, and
| | | | - Klaus Kaier
- 5Institute for Medical Biometry and Medical Informatics, University Medical Center Freiburg
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Symptomatic and silent cerebral infarction following surgical clipping of unruptured intracranial aneurysms: incidence, risk factors, and clinical outcome. Neurosurg Rev 2017; 41:675-682. [PMID: 28983720 DOI: 10.1007/s10143-017-0913-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 11/27/2022]
Abstract
Cerebral infarction (CI) associated with clipping of unruptured intracranial aneurysms (UIAs) has not been completely studied. The role of individual and operative characteristics is not known, and the risk of silent CI has not been well described. To determine the incidence, risk factors, and clinical outcome of postoperative CI, we retrospectively analyzed 388 consecutive patients undergoing clipping of UIAs between January 2012 and December 2015. We reviewed the pre- and postoperative computed tomography (CT) images of each patient. Postoperative CI was defined as a new parenchymal hypodensity in the vascular territory of treated artery. Patient-specific, aneurysm-specific, and operative variables were analyzed as potential risk factors. Functional outcome at discharge was assessed with the modified Rankin Scale (mRS). Postoperative CI was found in 49 (12.6%) patients, 29 of whom manifested neurological deficits. The incidences of symptomatic stroke and silent CI were 7.5 and 5.2%, respectively. Multivariate analysis showed that larger aneurysm size and history of hypertension were significantly associated with CI. Disability (mRS > 2) rate was 42.9% among patients with CI, which was substantially higher than that among patients without (0.9%). In conclusion, the incidence of CI following clipping of UIAs was not low. Larger aneurysm size and history of hypertension were independent risk factors. Postoperative symptomatic stroke correlated with an extremely high risk of disability. Silent CI was seemingly nondisabling, but the possible cognitive consequence is pending.
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Burkhardt JK, Chen X, Winkler EA, Weiss M, Yue JK, Cooke DL, Kim H, Lawton MT. Early Hemodynamic Changes Based on Initial Color-Coding Angiography as a Predictor for Developing Subsequent Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 109:e363-e373. [PMID: 28987853 DOI: 10.1016/j.wneu.2017.09.179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/24/2017] [Accepted: 09/25/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Prediction of vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) remains imperfect and currently relies on clinical and radiographic characteristics. Whether early hemodynamic changes may refine risk stratification for delayed vasospasm (DV) after aSAH was analyzed. METHODS Patients with aSAH (n = 53) and a control group with unruptured intracranial aneurysms (UIA) (n = 12) with initial color-coding angiography at admission were included in this study (n = 65). Clinical and radiologic data were collected, and uni- and multivariate analysis was used to correlate the occurrence of DV (manifesting clinically or detected with transcranial Doppler or angiography) with hemodynamic features of the initial angiography including Tmax and mean transit times (MTTs). RESULTS In the aSAH patient cohort, 37 of 53 patients with aSAH (70%) developed DV. After we controlled for the effects of age, Hunt and Hess grade, and modified Fisher grade, patients with DV had a shorter mean region of interest peak time (Tmax) of the anterior cerebral artery A2 segment (P = 0.036) and the middle cerebral artery M1 (P = 0.045) and M3 (P = 0.013) segments. Mean MTTs between internal carotid artery to middle cerebral artery M3 segment (P = 0.026) was also significantly shorter in patients with DV when compared with controls. CONCLUSIONS Tmax and MTT on angiography within 48 hours of aneurysm rupture before treatment provide an early quantitative assessment in patients with aSAH and in this small study were predictive for the development of subsequent symptomatic DV. Early identification of patients with aSAH at greatest risk of DV may ameliorate clinical outcome through timely, selective implementation of aggressive prophylactic therapy to prevent the effects of DV.
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Affiliation(s)
- Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Xiaolin Chen
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Miriam Weiss
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA; Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
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26
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Ghoshal S, Claassen J. Spreading depolarization and acute ischaemia in subarachnoid haemorrhage: the role of mass depolarization waves. Brain 2017; 140:2527-2529. [PMID: 28969392 DOI: 10.1093/brain/awx226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shivani Ghoshal
- Department of Neurology, Columbia University, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
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27
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Chou SHY, Lan J, Esposito E, Ning M, Balaj L, Ji X, Lo EH, Hayakawa K. Extracellular Mitochondria in Cerebrospinal Fluid and Neurological Recovery After Subarachnoid Hemorrhage. Stroke 2017; 48:2231-2237. [PMID: 28663512 DOI: 10.1161/strokeaha.117.017758] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/22/2017] [Accepted: 05/25/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Recent studies suggest that extracellular mitochondria may be involved in the pathophysiology of stroke. In this study, we assessed the functional relevance of endogenous extracellular mitochondria in cerebrospinal fluid (CSF) in rats and humans after subarachnoid hemorrhage (SAH). METHODS A standard rat model of SAH was used, where an intraluminal suture was used to perforate a cerebral artery, thus leading to blood extravasation into subarachnoid space. At 24 and 72 hours after SAH, neurological outcomes were measured, and the standard JC1 (5,5',6,6'-tetrachloro-1,1',3,3'-tetraethyl-benzimidazolylcarbocyanineiodide) assay was used to quantify mitochondrial membrane potentials in the CSF. To further support the rat model experiments, CSF samples were obtained from 41 patients with SAH and 27 control subjects. Mitochondrial membrane potentials were measured with the JC1 assay, and correlations with clinical outcomes were assessed at 3 months. RESULTS In the standard rat model of SAH, extracellular mitochondria was detected in CSF at 24 and 72 hours after injury. JC1 assays demonstrated that mitochondrial membrane potentials in CSF were decreased after SAH compared with sham-operated controls. In human CSF samples, extracellular mitochondria were also detected, and JC1 levels were also reduced after SAH. Furthermore, higher mitochondrial membrane potentials in the CSF were correlated with good clinical recovery at 3 months after SAH onset. CONCLUSIONS This proof-of-concept study suggests that extracellular mitochondria may provide a biomarker-like glimpse into brain integrity and recovery after injury.
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Affiliation(s)
- Sherry H-Y Chou
- From the Neuroprotection Research Laboratories, Departments of Radiology and Neurology (S.H.-Y.C., J.L., E.E., M.N., E.H.L., K.H.) and Clinical Proteomics Research Center, Department of Neurology (M.N., E.H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, PA (S.H.-Y.C.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.H.-Y.C.); Cerebrovascular Research Center, Xuanwu Hospital, Capital Medical University, Beijing, China (J.L., X.J.); and Department of Neurology, Massachusetts General Hospital and Program in Neuroscience, Harvard Medical School, Boston (L.B.)
| | - Jing Lan
- From the Neuroprotection Research Laboratories, Departments of Radiology and Neurology (S.H.-Y.C., J.L., E.E., M.N., E.H.L., K.H.) and Clinical Proteomics Research Center, Department of Neurology (M.N., E.H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, PA (S.H.-Y.C.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.H.-Y.C.); Cerebrovascular Research Center, Xuanwu Hospital, Capital Medical University, Beijing, China (J.L., X.J.); and Department of Neurology, Massachusetts General Hospital and Program in Neuroscience, Harvard Medical School, Boston (L.B.)
| | - Elga Esposito
- From the Neuroprotection Research Laboratories, Departments of Radiology and Neurology (S.H.-Y.C., J.L., E.E., M.N., E.H.L., K.H.) and Clinical Proteomics Research Center, Department of Neurology (M.N., E.H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, PA (S.H.-Y.C.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.H.-Y.C.); Cerebrovascular Research Center, Xuanwu Hospital, Capital Medical University, Beijing, China (J.L., X.J.); and Department of Neurology, Massachusetts General Hospital and Program in Neuroscience, Harvard Medical School, Boston (L.B.)
| | - MingMing Ning
- From the Neuroprotection Research Laboratories, Departments of Radiology and Neurology (S.H.-Y.C., J.L., E.E., M.N., E.H.L., K.H.) and Clinical Proteomics Research Center, Department of Neurology (M.N., E.H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, PA (S.H.-Y.C.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.H.-Y.C.); Cerebrovascular Research Center, Xuanwu Hospital, Capital Medical University, Beijing, China (J.L., X.J.); and Department of Neurology, Massachusetts General Hospital and Program in Neuroscience, Harvard Medical School, Boston (L.B.)
| | - Leonora Balaj
- From the Neuroprotection Research Laboratories, Departments of Radiology and Neurology (S.H.-Y.C., J.L., E.E., M.N., E.H.L., K.H.) and Clinical Proteomics Research Center, Department of Neurology (M.N., E.H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, PA (S.H.-Y.C.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.H.-Y.C.); Cerebrovascular Research Center, Xuanwu Hospital, Capital Medical University, Beijing, China (J.L., X.J.); and Department of Neurology, Massachusetts General Hospital and Program in Neuroscience, Harvard Medical School, Boston (L.B.)
| | - Xunming Ji
- From the Neuroprotection Research Laboratories, Departments of Radiology and Neurology (S.H.-Y.C., J.L., E.E., M.N., E.H.L., K.H.) and Clinical Proteomics Research Center, Department of Neurology (M.N., E.H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, PA (S.H.-Y.C.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.H.-Y.C.); Cerebrovascular Research Center, Xuanwu Hospital, Capital Medical University, Beijing, China (J.L., X.J.); and Department of Neurology, Massachusetts General Hospital and Program in Neuroscience, Harvard Medical School, Boston (L.B.)
| | - Eng H Lo
- From the Neuroprotection Research Laboratories, Departments of Radiology and Neurology (S.H.-Y.C., J.L., E.E., M.N., E.H.L., K.H.) and Clinical Proteomics Research Center, Department of Neurology (M.N., E.H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, PA (S.H.-Y.C.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.H.-Y.C.); Cerebrovascular Research Center, Xuanwu Hospital, Capital Medical University, Beijing, China (J.L., X.J.); and Department of Neurology, Massachusetts General Hospital and Program in Neuroscience, Harvard Medical School, Boston (L.B.)
| | - Kazuhide Hayakawa
- From the Neuroprotection Research Laboratories, Departments of Radiology and Neurology (S.H.-Y.C., J.L., E.E., M.N., E.H.L., K.H.) and Clinical Proteomics Research Center, Department of Neurology (M.N., E.H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, PA (S.H.-Y.C.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (S.H.-Y.C.); Cerebrovascular Research Center, Xuanwu Hospital, Capital Medical University, Beijing, China (J.L., X.J.); and Department of Neurology, Massachusetts General Hospital and Program in Neuroscience, Harvard Medical School, Boston (L.B.).
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Kubben PL, Germans MR, Jabbarli R. Delayed cerebral ischemia after subarachnoid hemorrhage: Comparing and integrating classification systems. Surg Neurol Int 2017; 8:121. [PMID: 28713625 PMCID: PMC5502297 DOI: 10.4103/2152-7806.208805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 12/12/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
- Pieter L Kubben
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht
| | - Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, Switzerland
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
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29
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Phan K, Moore JM, Griessenauer CJ, Xu J, Teng I, Dmytriw AA, Chiu AH, Ogilvy CS, Thomas A. Ultra-Early Angiographic Vasospasm After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2017; 102:632-638.e1. [PMID: 28365434 DOI: 10.1016/j.wneu.2017.03.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/10/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE After aneurysmal subarachnoid hemorrhage (aSAH), prognosis is affected heavily by the presence of delayed cerebral ischemia (DCI). There is growing recognition of ultra-early angiographic vasospasm (UEAV) occurring within 48 hours of aSAH; however, its relationship with DCI and ultimately prognosis remains unclear. METHODS Various databases limited to the English language through September 2016 were searched systematically. Eligible studies were those comparing UEAV with control non-UEAV outcomes and follow-up. Two independent reviewers evaluated the quality of studies and abstracted the data, with discrepancies resolved by a third. We calculated odds ratios (ORs) and 95% confidence intervals for all outcomes by using random-effects meta-analyses and performed a heterogeneity analysis. RESULTS Four comparative studies were selected for analysis. Pooled analysis demonstrated that UEAV compared with no-UEAV was associated with greater proportion of rupture aneurysms sized greater than 12 mm (38.3% vs. 24.3%, P < 0.00001). A significantly greater number of patients with UEAV had ruptured MCA aneurysms compared with patients without UEAV (29.7% vs. 19.9%, P = 0.005). Compared with no-UEAV, patients with UEAV were significantly associated with symptomatic cerebral vasospasm (OR 2.07, P = 0.05) and DCI/infarction (OR 2.52, P = 0.02). A significant association also was found between UEAV and an unfavorable outcome at follow-up (OR 1.64, P = 0.03) and greater mortality (OR 2.65, P < 0.00001). CONCLUSIONS UEAV was significantly associated with symptomatic cerebral vasospasm, DCI/infarction, unfavorable outcome at follow-up, and greater mortality. Patients with intracerebral hematoma, intraventricular hemorrhage (Fisher Grade IV), larger ruptured aneurysms >12 mm, and an MCA location were more likely to have UEAV.
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Affiliation(s)
- Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Justin M Moore
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph J Griessenauer
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Xu
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Ian Teng
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Adam A Dmytriw
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Albert H Chiu
- Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital and Community Health Services, Prince of Wales Clinical School, University of New South Wales, Randwick, Australia
| | - Christopher S Ogilvy
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith Thomas
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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30
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Duan G, Wen W, Zuo Q, Yang P, Zhang L, Hong B, Xu Y, Liu J, Huang Q. Development and Validation of the Procedure-Related Neurologic Complications Risk Score for Elderly Patients with Ruptured Intracranial Aneurysm Undergoing Endovascular Treatment. World Neurosurg 2017; 100:648-657.e2. [PMID: 28153618 DOI: 10.1016/j.wneu.2017.01.085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Our aim was to develop and validate a procedure-related neurologic complications (PNC) risk score for individual elderly patients with ruptured intracranial aneurysms undergoing endovascular treatment (EVT). METHODS Preoperatively collected data, including clinical, lesion, and procedure characteristics of consecutive elderly patients (≥60 years), were used to develop a PNC risk predictive score based on the coefficients (β) of a multivariable logistic regression analysis. The PNC included intraprocedural rupture, thromboembolic events, and rebleeding within 30 days after EVT. RESULTS Overall, 520 elderly patients who underwent EVT were enrolled. At 30 days, the PNC rate was 13.08%. Six risk factors were independently associated with PNC and comprised the PNC score (PNC score, 0-16 points): hypertension (2 points), Hunt-Hess grade ≥4 (3 points), Fisher grade ≥3 (2 points), wide-necked aneurysm (2 points), with a bleb on the aneurysm sac (3 points), and aneurysm size (3-10 mm, 1 point; <3 mm, 4 points). The PNC score model predicted the risk of PNC at a sensitivity of 63.22% and specificity of 84.79%. Moreover, the PNC score demonstrated significant discrimination (area under curve, 0.799; P < 0.001) and calibration (Hosmer-Lemeshow test, P = 0.319). Excellent prediction, discrimination, and calibration properties were reproduced by the internal validation group with bootstrapping techniques. CONCLUSIONS The PNC score can be an easily applicable tool for predicting the risk of PNC for individual elderly patients with ruptured intracranial aneurysms undergoing EVT. Our study provides large case-based evidence supporting the integration of individual clinical, lesion, and procedure characteristics to predict PNC risk.
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Affiliation(s)
- Guoli Duan
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wanling Wen
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qiao Zuo
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Lei Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
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Jabbarli R, Oppong MD, Dammann P, Wrede KH, El Hindy N, Özkan N, Müller O, Forsting M, Sure U. Time Is Brain! Analysis of 245 Cases with Decompressive Craniectomy due to Subarachnoid Hemorrhage. World Neurosurg 2017; 98:689-694.e2. [DOI: 10.1016/j.wneu.2016.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/04/2016] [Accepted: 12/05/2016] [Indexed: 12/14/2022]
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Witsch J, Frey HP, Patel S, Park S, Lahiri S, Schmidt JM, Agarwal S, Falo MC, Velazquez A, Jaja B, Macdonald RL, Connolly ES, Claassen J. Prognostication of long-term outcomes after subarachnoid hemorrhage: The FRESH score. Ann Neurol 2016; 80:46-58. [PMID: 27129898 DOI: 10.1002/ana.24675] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 04/19/2016] [Accepted: 04/19/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To create a multidimensional tool to prognosticate long-term functional, cognitive, and quality of life outcomes after spontaneous subarachnoid hemorrhage (SAH) using data up to 48 hours after admission. METHODS Data were prospectively collected for 1,619 consecutive patients enrolled in the SAH outcome project July 1996 to March 2014. Linear models (LMs) were applied to identify factors associated with outcome in 1,526 patients with complete data. Twelve-month functional, cognitive, and quality of life outcomes were measured using the modified Rankin scale (mRS), Telephone Interview for Cognitive Status, and Sickness Impact Profile. Based on the LM residuals, we constructed the FRESH score (Functional Recovery Expected after Subarachnoid Hemorrhage). Score performance, discrimination, and internal validity were tested using the area under the receiver operating characteristic curve (AUC), Nagelkerke and Cox/Snell R(2) , and bootstrapping. For external validation, we used a control population of SAH patients from the CONSCIOUS-1 study (n = 413). RESULTS The FRESH score was composed of Hunt & Hess and APACHE-II physiologic scores on admission, age, and aneurysmal rebleed within 48 hours. Separate scores to prognosticate 1-year cognition (FRESH-cog) and quality of life (FRESH-quol) were developed controlling for education and premorbid disability. Poor functional outcome (mRS = 4-6) for score levels 1 through 9 respectively was present in 3, 6, 12, 38, 61, 83, 92, 98, and 100% at 1-year follow-up. Performance of FRESH (AUC = 0.90), FRESH-cog (AUC = 0.80), and FRESH-quol (AUC = 0.78) was high. External validation of our cohort using mRS as endpoint showed satisfactory results (AUC = 0.77). To allow for convenient score calculation, we built a smartphone app available for free download. INTERPRETATION FRESH is the first clinical tool to prognosticate long-term outcome after spontaneous SAH in a multidimensional manner. Ann Neurol 2016;80:46-58.
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Affiliation(s)
- Jens Witsch
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Hans-Peter Frey
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Sweta Patel
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Soojin Park
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Shouri Lahiri
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - J Michael Schmidt
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Sachin Agarwal
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Maria Cristina Falo
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Angela Velazquez
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Blessing Jaja
- Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Institute of Medical Science, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Institute of Medical Science, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - E Sander Connolly
- Department of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Jan Claassen
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
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Malinova V, Schatlo B, Voit M, Suntheim P, Rohde V, Mielke D. Identification of specific age groups with a high risk for developing cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2016; 39:429-36. [PMID: 26940102 DOI: 10.1007/s10143-016-0701-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 11/07/2015] [Accepted: 11/30/2015] [Indexed: 11/28/2022]
Abstract
The impact of age on the incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is a matter of ongoing discussion. The aim of this study was to identify age groups with a higher risk for developing vasospasm, delayed ischemic neurological deficit (DIND), or delayed infarction (DI) and to identify a cut-off age for a better risk stratification. We defined six age groups (<30, 30-39, 40-49, 50-59, 60-69, and >70 years). ROC analysis was performed to determine a cutoff age with the highest positive predictive value (PPV) for developing vasospasm, defined as a blood-flow-velocity-increase >120 cm/s in transcranial-Doppler-sonography (TCD). Multivariate binary-logistic-regression-analysis was then performed to evaluate differences in the incidence of cerebral vasospasm, DIND, and DI among the different age groups. A total of 753 patients were included in the study. The highest incidence (70 %) of TCD-vasospasm was found in patients between 30 and 39 years of age. The cutoff age with the highest PPV (65 %) for developing TCD-vasospasm was 38 years. Multivariate analysis revealed that age <38 years (OR 3.6; CI 95 % 2.1-6.1; p < 0.001) best predicted vasospasm, followed by the need for cerebrospinal fluid drainage (OR 1.5; CI 95 % 1.0-2.3; p = 0.04). However, lower age did not correlate with higher rates of DIND or infarcts. The overall vasospasm-incidence after aSAH is age-dependent and highest in the age group <38 years. Surprisingly, the higher incidence in the younger age group does not translate into a higher rate of DIND/DI. This finding may hint towards age-related biological factors influencing the association between arterial narrowing and cerebral ischemia.
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Affiliation(s)
- Vesna Malinova
- Department of Neurosurgery, Georg August University, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Bawarjan Schatlo
- Department of Neurosurgery, Georg August University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Martin Voit
- Department of Neurosurgery, Georg August University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Patricia Suntheim
- Department of Neurosurgery, Georg August University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, Georg August University, Robert-Koch-Straße 40, 37075, Göttingen, Germany.,Department of Neurosurgery, RWTH University, Aachen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, Georg August University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
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Jabbarli R, Reinhard M, Shah M, Roelz R, Niesen WD, Kaier K, Taschner C, Weyerbrock A, Van Velthoven V. Early Vasospasm after Aneurysmal Subarachnoid Hemorrhage Predicts the Occurrence and Severity of Symptomatic Vasospasm and Delayed Cerebral Ischemia. Cerebrovasc Dis 2016; 41:265-72. [DOI: 10.1159/000443744] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 12/30/2015] [Indexed: 11/19/2022] Open
Abstract
Background: Cerebral vasospasm usually develops several days after subarachnoid hemorrhage (SAH) and is generally acknowledged as a strong outcome predictor. In contrast, much less is known about the nature and eventual consequences of early angiographic vasospasm (EAVS) seen on admission digital subtraction angiography (DSA). Therefore, we aimed at identifying the risk factors and clinical impact of EAVS after SAH. Methods: Five hundred and thirty-one SAH patients with admission DSA performed within 72 h after the bleeding event were selected from a comprehensive database containing all consecutive SAH patients treated at our institution between January 2005 and December 2012. Predictors of EAVS, as well as associations between EAVS and delayed vasospasm-related complications, and unfavorable outcome (defined as modified Rankin scale >3) were evaluated in univariate and multivariate analyses. Results: EAVS was seen on 60 DSAs (11.3%) and was independently correlated with delayed symptomatic vasospasm requiring intra-arterial spasmolysis (OR 5.24, p < 0.0001), angioplasty (OR 2.56, p = 0.015) and repetitive endovascular treatment (OR 4.71, p < 0.0001). EAVS also increased the risk for multiple versus single territorial infarction on the follow-up CT scan(s) (OR 2.04, p = 0.047) and independently predicted unfavorable outcome (OR 2.93, p = 0.008). The presence of radiographic signs suspicious for fibromuscular dysplasia were independently associated with the occurrence of EAVS (OR 2.98, p = 0.026) and the need for repetitive endovascular vasospasm treatment (OR 3.95, p = 0.019). Conclusions: In view of the strong correlation with delayed symptomatic vasospasm and its ischemic complications, EAVS can be considered an alerting signal for severe symptomatic vasospasm. Therefore, more attention should be paid to the presence of EAVS on admission DSA.
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Duan G, Yang P, Li Q, Zuo Q, Zhang L, Hong B, Xu Y, Zhao W, Liu J, Huang Q. Prognosis Predicting Score for Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage: A Risk Modeling Study for Individual Elderly Patients. Medicine (Baltimore) 2016; 95:e2686. [PMID: 26886607 PMCID: PMC4998607 DOI: 10.1097/md.0000000000002686] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/09/2015] [Accepted: 01/11/2016] [Indexed: 11/30/2022] Open
Abstract
The elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) have a greater risk of poor clinical outcome after endovascular treatment (EVT) than younger patients do. Hence, it is necessary to explore which factors are associated with poor outcome and develop a predictive score specifically for elderly patients with aSAH receiving EVT. The aim of this study was to develop and validate a predictive score for 1-year outcomes in individual elderly patients with aSAH underwent EVT.In this 10-year prospective study, 520 consecutive aSAH elderly (age ≥ 60 years) patients underwent EVT in a single center were included. The risk factors, periprocedural, and 1-year follow-up data of all patients were entered in a specific prospective database. The modified Rankin scale was used for evaluating clinical outcome. To optimize the model's predictive capacity, the original matrix was randomly divided in 2 submatrices (learning and testing). The predictive score was developed using Arabic numerals for all variables based on the variable coefficients (β) of multivariable logistic regression analysis in the learning set and the predictive performance evaluation was assessed in the testing set. The risk classes were constructed using classification criteria based on sensitivity and specificity. The poor outcome rate at 1 year was 26.15%. Six risk factors, including age, hypertension, Hunt-Hess scale, Fisher scale, aneurysm location, and periprocedural complications, were independently associated with poor outcome and assembled the Changhai score. The discriminative power analysis with the area under the receiver operating characteristic curve (AUC) of the Changhai score was statistically significant (0.864, 0.824-0.904, P < 0.001). The sensitivity and specificity of the Changhai score were 82.07% and 78.06%, respectively. Our study indicated that age, hypertension, Hunt-Hess scale, Fisher scale, aneurysm location, and periprocedural complications were independent risk factors of poor outcome for elderly aSAH patients underwent EVT. In combination with these risk factors, the Changhai score can be a useful tool in the prediction of clinical outcome but needs to be validated in various centers before it can be recommended for application.
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Affiliation(s)
- Guoli Duan
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
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36
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Jabbarli R, Wrede KH, Pierscianek D, Dammann P, El Hindy N, Özkan N, Müller O, Stolke D, Forsting M, Sure U. Outcome After Clipping of Unruptured Intracranial Aneurysms Depends on Caseload. World Neurosurg 2015; 89:666-671.e1. [PMID: 26732965 DOI: 10.1016/j.wneu.2015.12.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 12/08/2015] [Accepted: 12/10/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although most neurovascular centers currently have a coil first policy, the percentage of coiled versus clipped aneurysms, as well as treatment outcomes, varies strongly between these centers. This study evaluates the impact of an increase in clipping caseload on treatment outcome in a large single-center series. METHODS All consecutive patients who underwent microsurgical clipping of unruptured intracranial aneurysms between January 2003 and April 2014 in our department were analyzed retrospectively. According to the change of the chairman in the neurosurgical department (1 September 2008) with a subsequent increase in the clipping volume, the entire cohort was divided into 2 groups with equal time intervals (historic and current cohorts). RESULTS There were 94 clipped unruptured intracranial aneurysms in the historic cohort and 252 in the current cohort. Unfavorable outcome at 6 months postoperatively (defined as modified Rankin Score >2) was observed in 8 cases (8.5%) in the historic cohort and 7 cases (2.8%) in the current cohort (P < 0.0001). The surgical mortality decreased from 3.2% to 0%. Cerebral infarction on postoperative computed tomography scan was observed in 25 cases (26.6%) in the historic cohort and 19 cases (7.5%) in the current cohort (P < 0.0001). Within the current cohort, there was a progressive improvement of surgical outcome over the time. CONCLUSIONS The improvement of the surgical outcome after increasing the clipping caseload underlines the importance of sufficient surgical volume for maintenance of competitive treatment results.
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Affiliation(s)
- Ramazan Jabbarli
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany.
| | - Karsten H Wrede
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | | | - Philipp Dammann
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Nicolai El Hindy
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Neriman Özkan
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Oliver Müller
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Dietmar Stolke
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital of Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
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37
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Turan N, Heider RAJ, Zaharieva D, Ahmad FU, Barrow DL, Pradilla G. Sex Differences in the Formation of Intracranial Aneurysms and Incidence and Outcome of Subarachnoid Hemorrhage: Review of Experimental and Human Studies. Transl Stroke Res 2015; 7:12-9. [PMID: 26573918 DOI: 10.1007/s12975-015-0434-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/05/2015] [Accepted: 11/09/2015] [Indexed: 12/26/2022]
Abstract
Intracranial aneurysms are defined as pathological dilatations of cerebral arteries and rupture of intracranial aneurysms leads to subarachnoid hemorrhage (SAH). The goal of this review was to outline the sex differences in the formation and progression of intracranial aneurysms as well as sex-related differences in incidence and outcome of SAH. The literature review was performed using PubMed with a combination of these search terms: "subarachnoid hemorrhage," "incidence," "outcome," "sex," "gender," "male," "female," "experimental," "mice," and "rats." Studies written in English were used. Female sex is thought to be a risk factor for aneurysm formation, especially in postmenopausal age populations, suggesting the potential protective involvement of sex steroids. Female sex is also considered a risk factor for SAH occurrence. Although incidence and mortality are confirmed to be higher in females in most studies, they elucidated no clear differences in the functional outcome among SAH survivors. The effect of gender on the pathophysiology of SAH is not very well understood; nevertheless, the majority of pre-clinical studies suggest a beneficial effect of sex steroids in experimental SAH. Moreover, conflicting results exist on the role and effect of hormone replacement therapies and oral contraceptive pills on the incidence and outcome of human SAH. Sex differences exist in the formation of aneurysms as well as the incidence and mortality of SAH. Potential therapeutic effects of sex steroids have been replicated in many animal studies, but their potential use in the treatment of acute SAH in human populations needs more future study.
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Affiliation(s)
- Nefize Turan
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Rd. NE, Suite B6166, Atlanta, GA, 30322, USA
| | - Robert Allen-James Heider
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Rd. NE, Suite B6166, Atlanta, GA, 30322, USA
| | - Dobromira Zaharieva
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Rd. NE, Suite B6166, Atlanta, GA, 30322, USA
| | - Faiz U Ahmad
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Rd. NE, Suite B6166, Atlanta, GA, 30322, USA
| | - Daniel L Barrow
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Rd. NE, Suite B6166, Atlanta, GA, 30322, USA
| | - Gustavo Pradilla
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Rd. NE, Suite B6166, Atlanta, GA, 30322, USA.
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