The Prognostic Significance of a Cast Fourth Ventricle in Ruptured Aneurysm Patients With Intraventricular Hemorrhage in the Barrow Ruptured Aneurysm Trial (BRAT)

Sex differences in patients with and without high-risk factors associated with aneurysmal subarachnoid hemorrhage

BACKGROUND

Controversy remains regarding the appropriate screening for intracranial aneurysms or for the treatment of aneurysmal subarachnoid hemorrhage (aSAH) for patients without known high-risk factors for rupture. This study aimed to assess how sex affects both aSAH presentation and outcomes for aSAH treatment.

METHOD

A retrospective cohort study was conducted of all patients treated at a single institution for an aSAH during a 12-year period (August 1, 2007-July 31, 2019). An analysis of women with and without high-risk factors was performed, including a propensity adjustment for a poor neurologic outcome (modified Rankin Scale [mRS] score > 2) at follow-up.

RESULTS

Data from 1014 patients were analyzed (69% [n = 703] women). Women were significantly older than men (mean ± SD, 56.6 ± 14.1 years vs 53.4 ± 14.2 years, p < 0.001). A significantly lower percentage of women than men had a history of tobacco use (36.6% [n = 257] vs 46% [n = 143], p = 0.005). A significantly higher percentage of women than men had no high-risk factors for aSAH (10% [n = 70] vs 5% [n = 16], p = 0.01). The percentage of women with an mRS score > 2 at the last follow-up was significantly lower among those without high-risk factors (34%, 24/70) versus those with high-risk factors (53%, 334/633) (p = 0.004). Subsequent propensity-adjusted analysis (adjusted for age, Hunt and Hess grade, and Fisher grade) found no statistically significant difference in the odds of a poor outcome for women with or without high-risk factors for aSAH (OR = 0.7, 95% CI = 0.4-1.2, p = 0.18).

CONCLUSIONS

A higher percentage of women versus men with aSAH had no known high-risk factors for rupture, supporting more aggressive screening and management of women with unruptured aneurysms.

Cerebrospinal fluid drainage and chronic hydrocephalus in aneurysmal subarachnoid hemorrhage patients with intraventricular hemorrhage

Background

Patients with intraventricular hemorrhage (IVH) are at a higher risk of developing hydrocephalus and often require external ventricular drainage or long-term ventriculoperitoneal shunt surgery.

Objective

To investigate whether cerebrospinal fluid drainage in patients with IVH due to aneurysmal subarachnoid hemorrhage (aSAH) reduces the incidence of chronic hydrocephalus.

Method

A retrospective analysis was conducted on patients with aSAH treated at our hospital between January 2020 and December 2022. The first analysis compared patients with and without IVH, while the second analysis compared IVH patients with and without chronic hydrocephalus. The third analysis compared IVH patients who underwent in different drainage methods which is lumbar drainage (LD) or external ventricular drainage (EVD). The primary outcome measure was the incidence of chronic hydrocephalus.

Result

Of the 296 patients hospitalized with aSAH, 108 (36.5%) had IVH, which was associated with a significantly higher incidence of chronic hydrocephalus compared to patients without IVH (49.1% vs. 16.5%, p < 0.001). Multivariate logistic regression analysis showed that IVH was independently associated with the formation of chronic hydrocephalus (OR: 3.530, 95% CI: 1.958-6.362, p < 0.001). Among the 108 IVH patients, 53 (49.1%) developed chronic hydrocephalus. Multivariate logistic regression analysis revealed that the Hunt Hess grade at admission (OR: 3.362, 95% CI: 1.146-9.863, p = 0.027) and postoperative cerebrospinal fluid drainage (OR: 0.110, 95% CI: 0.036-0.336, p < 0.001) were independent risk factors for the development of chronic hydrocephalus in IVH patients. Among all IVH patients who underwent cerebrospinal fluid drainage, 45 (75%) received continuous lumbar puncture drainage, and 15 (25%) received external ventricular drainage. Univariate analysis did not show a statistically significant difference between the two groups in terms of postoperative chronic hydrocephalus (p = 0.283). However, multivariate logistic regression analysis suggested that the drainage methods of LD and EVD might be associated with the development of chronic hydrocephalus.

Conclusion

The presence of IVH increases the risk of chronic hydrocephalus in patients with aSAH, and postoperative cerebrospinal fluid drainage appears to reduce this risk. The specific effects of lumbar puncture drainage and ventricular drainage on the incidence of chronic hydrocephalus require further investigation.

Spontaneous subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.

The times they are a-changin': increasing complexity of aneurysmal subarachnoid hemorrhages in patients treated from 2004 to 2018

BACKGROUND

Nationwide study results have suggested varying trends in the incidence of aneurysmal subarachnoid hemorrhage (aSAH) over time. Herein, trends over time for aSAH treated at a quaternary care center are compared to low-volume hospitals.

METHODS

Cases were retrospectively reviewed for patients with aSAH treated at our institution. Trend analyses were performed on the number of aSAH hospitalizations, treatment type, Charlson Comorbidity Index (CCI), Hunt and Hess (HH) grade, aneurysm location, aneurysm type, and in-hospital mortality. The National Inpatient Sample (NIS) was queried to compare the CCI scores of our patients with those of patients in low-volume hospitals (<20 aSAH/year) in our census division.

RESULTS

Some 1248 patients (321 during 2004-2006; 927 during 2008-2018) hospitalized with aSAH were treated with endovascular therapy (489, 39%) or microsurgery (759, 61%). A significant downtrend in the annual aSAH caseload occurred (123 patients in 2004, 75 in 2018, p<0.001). A linear uptrend was observed for the mean CCI score of patients (R²=0.539, p<0.001), with no change to in-hospital mortality (R²=0.220, p=0.24). Mean (SD) CCI for small-volume hospitals treating aSAH within our division was significantly lower than that of our patient population (1.8 [1.6] vs 2.1 [2.0]) for 2012-2015.

CONCLUSIONS

A decreasing number of patients were hospitalized with aSAH throughout the study. Compared with patients with aSAH admitted in 2004, those admitted more recently were sicker in terms of preexisting comorbidity and neurologic complexity. These trends could be attributable to the increasing availability of neurointerventional services at smaller-volume hospitals capable of treating healthier patients.

Intraventricular Tissue Plasminogen Activator and Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage Patients With Cast Ventricles

BACKGROUND

Patients with intraventricular hemorrhage (IVH) are at higher risk of hydrocephalus requiring an external ventricular drain and long-term ventriculoperitoneal shunt placement.

OBJECTIVE

To investigate whether intraventricular tissue plasminogen activator (tPA) administration in patients with ventricular casting due to IVH reduces shunt dependence.

METHODS

Patients from the Post-Barrow Ruptured Aneurysm Trial (PBRAT) database treated for aneurysmal subarachnoid hemorrhage (aSAH) from August 1, 2010, to July 31, 2019, were retrospectively reviewed. Patients with and without IVH were compared. A second analysis compared IVH patients with and without ventricular casting. A third analysis compared patients with ventricular casting with and without intraventricular tPA treatment. The primary outcome was chronic hydrocephalus requiring permanent shunt placement.

RESULTS

Of 806 patients hospitalized with aSAH, 561 (69.6%) had IVH. IVH was associated with a higher incidence of shunt placement (25.7% vs 4.1%, P < .001). In multivariable logistic regression analysis, IVH was independently associated with increased likelihood of shunt placement (odds ratio [OR]: 7.8, 95% CI: 3.8-16.2, P < .001). Generalized ventricular casting was present in 80 (14.3%) patients with IVH. In a propensity-score adjusted analysis, generalized ventricular casting was an independent predictor of shunt placement (OR: 3.0, 95% CI: 1.8-4.9, P < .001) in patients with IVH. Twenty-one patients with ventricular casting received intraventricular tPA. These patients were significantly less likely to require a shunt (OR: 0.30, 95% CI: 0.010-0.93, P = .04).

CONCLUSION

Ventricular casting in aSAH patients was associated with an increased risk of chronic hydrocephalus and shunt dependency. However, this risk decreased with the administration of intraventricular tPA.