Increased Body Mass Index Associated With Reduced Risk of Delayed Cerebral Ischemia and Subsequent Infarction After Aneurysmal Subarachnoid Hemorrhage

New grading scale based on early factors for predicting delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage: a multicenter retrospective study

Delayed cerebral ischemia (DCI) could lead to poor clinical outcome(s). The aim of the present study was to establish and validate a predictive model for DCI after aneurysmal subarachnoid hemorrhage (aSAH) based on clinical data. Data from a series of 217 consecutive patients with aSAH were reviewed and analyzed. Related risk factors within 72 h after aSAH were analyzed depending on whether DCI recurred. Least absolute shrinkage and selection operator (LASSO) analysis was performed to reduce data dimensions and screen for optimal predictors. Multivariable logistic regression was used to establish a predictive model and construct a nomogram. Receiver operating characteristic (ROC) and calibration curves were generated to assess the discriminative ability and goodness of fit of the model. Decision curve analysis was applied to evaluated the clinical applicability of the predictive model. LASSO regression identified 4 independent predictors, including Subarachnoid Hemorrhage Early Brain Edema Score (i.e., "SEBES"), World Federation of Neurosurgical Societies scale score (i.e., "WFNS"), modified Fisher Scale score, and intraventricular hemorrhage (IVH), which were incorporated into logistic regression to develop a nomogram. After verification, the area under the ROC curve for the model was 0.860. The calibration curve indicated that the predictive probability of the new model was in good agreement with the actual probability, and decision curve analysis demonstrated the clinical applicability of the model within a specified range. The prediction model could precisely calculate the probability of DCI after aSAH, and may contribute to better clinical decision-making and personalized treatment to achieve better outcomes.

Risk Factors for Delayed Cerebral Ischemia in Good-Grade Patients With Aneurysmal Subarachnoid Hemorrhage

Background A subset of good-grade patients with aneurysmal subarachnoid hemorrhage (aSAH) develop delayed cerebral ischemia (DCI) that may cause permanent disabilities after aSAH. However, little is known about the risk factors of DCI among this specific patient group. Methods and Results We obtained a multinational cohort of good-grade (Glasgow Coma Scale 13-15 on admission) patients with aSAH by pooling patient data from 4 clinical trials and 2 prospective cohort studies. We collected baseline data on lifestyle-related factors and the clinical characteristics of aSAHs. By calculating fully adjusted risk estimates for DCI and DCI-related poor outcome, we identified the most high-risk patient groups. The pooled study cohort included 1918 good-grade patients with aSAH (median age, 51 years; 64% women), of whom 21% and 7% experienced DCI and DCI-related poor outcome, respectively. Among men, patients with obesity and (body mass index ≥30 kg/m²) thick aSAH experienced most commonly DCI (33%) and DCI-related poor outcome (20%), whereas none of the normotensive or young (aged <50 years) men with low body mass index (body mass index <22.5 kg/m²) had DCI-related poor outcome. In women, the highest prevalence of DCI (28%) and DCI-related poor outcome (13%) was found in patients with preadmission hypertension and thick aSAH. Conversely, the lowest rates (11% and 2%, respectively) were observed in normotensive women with a thin aSAH. Conclusions Increasing age, thick aSAH, obesity, and preadmission hypertension are risk factors for DCI in good-grade patients with aSAH. These findings may help clinicians to consider which good-grade patients with aSAH should be monitored carefully in the intensive care unit.

Emergent Subarachnoid Clot Removal with Aneurysm Repair for Subarachnoid Hemorrhage Might Improves Clinical Outcome

BACKGROUND

The goal in treating patients with subarachnoid hemorrhage (SAH) is shifting to preventing early brain injury. Intracranial pressure must be controlled to manage such an injury. We retrospectively analyzed the impact of aggressive removal of cisternal subarachnoid clots with simultaneous aneurysm repair for all grades of SAH.

METHODS

Our study included 260 consecutive patients with SAH treated through aggressive subarachnoid clot removal with simultaneous aneurysm repair. Baseline patient characteristics, history, radiographic findings, and time of SAH onset to arrival in the operating room were retrospectively collected. Factors related to poor outcome (modified Rankin Scale score >2) were analyzed.

RESULTS

Multivariate analysis revealed several characteristics were significantly associated with poor outcome: advanced age (adjusted odds ratio [aOR] 1.07, 95% confidence interval [CI] 1.04-01.10); time of SAH onset to operating room per 1-hour increments (aOR 1.03, 95% CI 1.01-01.05; postoperative hematoma volume (aOR 1.04, 95% CI 1.01-01.06); and poorer World Federation of Neurosurgical Societies grade (aOR 2.18, 95% CI 1.63-02.92). According to a receiver operating characteristic analysis, the cut-off time of SAH onset to operating room was 6.0 hours (area under the curve 0.61, P = 0.01, 95% CI 0.52-0.69, sensitivity = 0.79, specificity = 0.43) as the threshold between modified Rankin Scale scores of 0-2 and 3-6.

CONCLUSIONS

Prognostic factors of SAH in patients undergoing emergent aneurysm repair with simultaneous removal of a cisternal subarachnoid clot are advanced age, poorer World Federation of Neurosurgical Societies grade, postoperative hematoma volume, and a longer time from SAH onset to operating room. The clinical outcome may improve with emergent reduction of intracranial pressure through removal of the subarachnoid clot as soon as possible.

Association Between Body Mass Index and Intracranial Aneurysm Rupture: A Multicenter Retrospective Study

Background and Aims: It has recently emerged the concept of “obesity paradox,” a term used to describe an inverse association between obesity and clinical outcomes in cardiovascular diseases and stroke. The purpose of this study was to investigate the association between body mass index (BMI) and the risk of intracranial aneurysm rupture.

Methods: In this study, we conducted a retrospective analysis of a prospectively maintained database of patients with intracranial aneurysms from 21 medical centers in China. A total of 3,965 patients with 4,632 saccular intracranial aneurysms were enrolled. Patients were separated into unruptured (n = 1,977) and ruptured groups (n = 1,988). Univariable and multivariable logistic regression analyses were performed to determine the association between BMI and intracranial aneurysm rupture.

Results: Compared to the patients with normal BMI (18.5 to < 24.0 kg/m²), the odds of intracranial aneurysm rupture were significantly lower in patients with BMI 24.0 to < 28.0 kg/m² (OR = 0.745, 95% CI = 0.638–0.868, P = 0.000) and patients with BMI ≥ 28.0 kg/m² (OR = 0.628, 95% CI = 0.443–0.890, P = 0.009). Low BMI (<18.0 kg/m²) was not associated with intracranial aneurysm rupture (OR = 0.894, 95% CI = 0.483–1.657, P = 0.505). For males, both the BMI 24.0 to < 28.0 kg/m² (OR = 0.606, 95% CI = 0.469–0.784, P = 0.000) and the BMI ≥ 28.0 kg/m² (OR = 0.384, 95% CI = 0.224–0.658, P = 0.001) were associated with a lower rupture risk, whereas the inverse association was not observed in females. Both the BMI 24.0 to < 28.0 kg/m² (OR = 0.722 for aged 50–60y, 95% CI = 0.554–0.938, P = 0.015; OR = 0.737 for aged >60y, 95% CI = 0.586–0.928, P = 0.009) and the BMI ≥ 28.0 kg/m² (OR = 0.517 for aged 50–60y, 95% CI = 0.281–0.950, P = 0.0034; OR = 0.535 for aged >60y, 95% CI = 0.318–0.899, P = 0.0018) was associated with a lower rupture risk in patients aged ≥50 years, whereas the association was not significant in patients aged <50 years.

Conclusions: Increased BMI is significantly and inversely associated with saccular intracranial aneurysm rupture in males and patients aged ≥50 years.

Body mass index and leptin levels in serum and cerebrospinal fluid in relation to delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is associated with a high mortality rate and may leave surviving patients severely disabled. After the initial hemorrhage, clinical outcome is further compromised by the occurrence of delayed cerebral ischemia (DCI). Overweight and obesity have previously been associated with protective effects in the post-bleeding phase. The aim of this study was to assess the effects of a patient’s body mass index (BMI) and leptin levels on the occurrence of DCI, DCI-related cerebral infarction, and clinical outcome. In total, 263 SAH patients were included of which leptin levels were assessed in 24 cases. BMI was recorded along disease severity documented by the Hunt and Hess and modified Fisher scales. The occurrence of clinical or functional DCI (neuromonitoring, CT Perfusion) was assessed. Long-term clinical outcome was documented after 12 months (extended Glasgow outcome scale). A total of 136 (51.7%) patients developed DCI of which 72 (27.4%) developed DCI-related cerebral infarctions. No association between BMI and DCI occurrence (P = .410) or better clinical outcome (P = .643) was identified. Early leptin concentration in serum (P = .258) and CSF (P = .159) showed no predictive value in identifying patients at risk of unfavorable outcomes. However, a significant increase of leptin levels in CSF occurred from 326.0 pg/ml IQR 171.9 prior to DCI development to 579.2 pg/ml IQR 211.9 during ongoing DCI (P = .049). In our data, no association between obesity and clinical outcome was detected. After DCI development, leptin levels in CSF increased either by an upsurge of active transport or disruption of the blood-CSF barrier. This trial has been registered at ClinicalTrials.gov (NCT02142166) as part of a larger-scale prospective data collection. BioSAB: https://clinicaltrials.gov/ct2/show/NCT02142166

Comparison of aneurysmal subarachnoid hemorrhage grading scores in patients with aneurysm clipping and coiling

Past studies revealed the prognosis differed between aneurysmal subarachnoid hemorrhage (aSAH) patients with surgical clipping and endovascular coiling. We retrospectively reviewed aSAH patients in our institution to investigate the effectiveness of grading scores between two groups. In the surgical clipping group (n = 349), VASOGRADE had a favorable performance for predicting delayed cerebral ischemia (DCI) (area under curve (AUC) > 0.750), and had better results than clinical (World Federation of Neurosurgical Societies (WFNS), Hunt & Hess (HH) and radiological scores (modified Fisher Scale (mFS), Subarachnoid Hemorrhage Early Brain Edema Score) (P < 0.05). Clinical and combined scores (VASOGRADE, HAIR) had favorable performance for predicting poor outcome (AUC > 0.750), and had better results than radiological scores (P < 0.05). In the coiling group (n = 320), none of the grading scores demonstrated favorable predictive accuracy for DCI (AUC < 0.750). Only WFNS and VASOGRADE had AUC > 0.700, with better performance than mFS (P < 0.05). The clinical and combined scores showed favorable performance for predicting a poor outcome (AUC > 0.750), and were better than the radiological scores (P < 0.05). Radiological scores appeared inferior to the clinical and combined scores in clipping and coiling groups. VASOGRADE can be an effective grading score in patients with clipping or coiling for predicting DCI and poor outcome.

New risk score of the early period after spontaneous subarachnoid hemorrhage: For the prediction of delayed cerebral ischemia

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.