Effect of acute physiologic derangements on outcome after subarachnoid hemorrhage

Nimodipine-associated standard dose reductions and neurologic outcomes after aneurysmal subarachnoid hemorrhage: the era of pharmacogenomics

Nimodipine, an L-type cerebroselective calcium channel antagonist, is the only drug approved by the US Food and Drug Administration for the neuroprotection of patients with aneurysmal subarachnoid hemorrhage (aSAH). Four randomized, placebo-controlled trials of nimodipine demonstrated clinical improvement over placebo; however, these occurred before precision medicine with pharmacogenomics was readily available. The standard enteral dose of nimodipine recommended after aSAH is 60 mg every 4 h. However, up to 78% of patients with aSAH develop systemic arterial hypotension after taking the drug at the recommended dose, which could theoretically limit its neuroprotective role and worsen cerebral perfusion pressure and cerebral blood flow, particularly when concomitant vasospasm is present. We investigated the association between nimodipine dose changes and clinical outcomes in a consecutive series of 150 patients (mean age, 56 years; 70.7% women) with acute aSAH. We describe the pharmacogenomic relationship of nimodipine dose reduction with clinical outcomes. These results have major implications for future individualized dosing of nimodipine in the era of precision medicine.

The role of early cerebral edema and hematoma assessment in aneurysmal subarachnoid hemorrhage (a-SAH) in predicting early brain injury (EBI) and cognitive impairment: a case controlled study

BACKGROUND

Early assessment and management of cerebral edema and hematoma following aneurysmal subarachnoid hemorrhage (a-SAH) can significantly impact clinical cognitive outcomes. However, current clinical practices lack predictive models to identify early structural brain abnormalities affecting cognition. To address this gap, the authors propose the development of a predictive model termed the a-SAH Early Brain Edema/Hematoma Compression Neural (Structural Brain) Networks Score System (SEBE-HCNNSS).

METHODS

In this study, 202 consecutive patients with spontaneous a-SAH underwent initial computed tomography (CT) or MRI scans within 24 h of ictus with follow-up 2 months after discharge. Using logistic regression analysis (univariate and multivariate), the authors evaluated the association of clinically relevant factors and various traditional scale ratings with cognitive impairment (CI). Risk factors with the highest area under the curve (AUC) values were included in the multivariate analysis and least absolute shrinkage and selection operator (LASSO) analysis or Cox regression analysis.

RESULTS

A total of 177 patients were enrolled in the study, and 43 patients were classified with a high SEBE-HCNNSS grade (3-5). After a mean follow-up of 2 months, 121 individuals (68.36%) with a-SAH and three control subjects developed incident CI. The CT interobserver reliability of the SEBE-HCNNSS scale was high, with a Kappa value of 1. Furthermore, ROC analysis identified the SEBE-HCNNSS scale (OR 3.322, 95% CI: 2.312-7.237, P =0.00025) as an independent predictor of edema, CI, and unfavorable prognosis. These results were also replicated in a validation cohort.

CONCLUSION

Overall, the SEBE-HCNNSS scale represents a simple assessment tool with promising predictive value for CI and clinical outcomes post-a-SAH. Our findings indicate its practical utility as a prognostic instrument for risk evaluation after a-SAH, potentially facilitating early intervention and treatment.

A nomogram for the prediction of short-term mortality in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation: a post-hoc analysis

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating stroke subtype with high morbidity and mortality. Although several studies have developed a prediction model in aSAH to predict individual outcomes, few have addressed short-term mortality in patients requiring mechanical ventilation. The study aimed to construct a user-friendly nomogram to provide a simple, precise, and personalized prediction of 30-day mortality in patients with aSAH requiring mechanical ventilation.

Methods

We conducted a post-hoc analysis based on a retrospective study in a French university hospital intensive care unit (ICU). All patients with aSAH requiring mechanical ventilation from January 2010 to December 2015 were included. Demographic and clinical variables were collected to develop a nomogram for predicting 30-day mortality. The least absolute shrinkage and selection operator (LASSO) regression method was performed to identify predictors, and multivariate logistic regression was used to establish a nomogram. The discriminative ability, calibration, and clinical practicability of the nomogram to predict short-term mortality were tested using the area under the curve (AUC), calibration plot, and decision curve analysis (DCA).

Results

Admission GCS, SAPS II, rebleeding, early brain injury (EBI), and external ventricular drain (EVD) were significantly associated with 30-day mortality in patients with aSAH requiring mechanical ventilation. Model A incorporated four clinical factors available in the early stages of the aSAH: GCS, SAPS II, rebleeding, and EBI. Then, the prediction model B with the five predictors was developed and presented in a nomogram. The predictive nomogram yielded an AUC of 0.795 [95% CI, 0.731-0.858], and in the internal validation with bootstrapping, the AUC was 0.780. The predictive model was well-calibrated, and decision curve analysis further confirmed the clinical usefulness of the nomogram.

Conclusion

We have developed two models and constructed a nomogram that included five clinical characteristics to predict 30-day mortality in patients with aSAH requiring mechanical ventilation, which may aid clinical decision-making.

Relationship between baseline bicarbonate and 30-day mortality in patients with non-traumatic subarachnoid hemorrhage

Objective

This study aimed to explore the relationship between baseline bicarbonate levels and 30-day mortality in individuals with non-traumatic subarachnoid hemorrhage (SAH).

Methods

Patients with non-traumatic SAH were chosen from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The relationship between baseline bicarbonate and 30-day mortality was examined using Cox regression models. Restricted cubic splines were used to test the hypothesis that there was an association between bicarbonate and mortality. With the use of Kaplan-Meier survival curve analysis, we looked deeper into the validity of these correlations. To find subgroups with differences, interaction tests were utilized.

Results

This retrospective cohort study consisted of 521 participants in total. Bicarbonate had a negative association with death at 30 days (HR = 0.93, 95%CI: 0.88-0.98, p = 0.004). Next, we divided bicarbonate into quartile groups. In comparison to the reference group Q1 (20 mEq/L), groups Q3 (23-25 mEq/L) and Q4 (26 mEq/L) had adjusted HR values of 0.47 (95%CI: 0.27-0.82, p = 0.007) and 0.56 (95%CI: 0.31-0.99, p = 0.047). No definite conclusions can be derived from this study, since there is no obvious curve link between baseline bicarbonate and 30-day mortality. Patients' 30-day mortality increased statistically significantly (p < 0.001, K-M analysis) in patients with low bicarbonate levels. The relationship between bicarbonate and 30-day mortality remained consistent in the stratified analysis, with no observed interactions.

Conclusion

Finally, 30-day mortality was negatively associated with baseline bicarbonate levels. Patients with non-traumatic SAH are more at risk of mortality if their bicarbonate levels are low.

Additive prognostic impact of the cerebrospinal fluid arginine/ornithine ratio to established clinical scores in aneurysmal subarachnoid hemorrhage

Cerebrospinal fluid (CSF) metabolites are increasingly recognized as prognostic factors in aneurysmal subarachnoid hemorrhage (SAH). The CSF arginine/ornithine ratio (Arg/Orn) was shown to predict cerebral vasospasms and clinical outcome in SAH. The additive prognostic value of Arg/Orn over established prognostic scores has not been investigated. CSF Arg/Orn and the established prognostic scores SAH, FRESH, SAH-PDS, HAIR, Rosen-McDonald, Hunt and Hess, WFNS and modified Fisher scale were determined in a prospective cohort of patients with aneurysmal SAH. Logistic regression models to predict a favorable outcome, defined as a modified Rankin Scale score of 0-3 at 3  months follow-up, were constructed for each score, both with and without the addition of Arg/Orn. The impact of Arg/Orn was assessed comparing logistic regression models containing the respective score with and without Arg/Orn with the likelihood ratio chi-squared test. CSF Arg/Orn and clinical scores were determined in 38 SAH patients. Arg/Orn was an independent predictor of clinical outcome when added to established prognostic scores (p < 0.05) with the exception of HAIR (p = 0.078). All models were significantly improved if Arg/Orn was added as a covariable (p < 0.05). The results of this study confirm Arg/Orn as an independent prognostic factor and its addition improves established prognostic models in SAH.

The prognostic value of hyperglycemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Recent studies have demonstrated that hyperglycemia may result in a poor prognosis following aneurysmal subarachnoid hemorrhage (aSAH). However, the association between hyperglycemia and the clinical outcome of aSAH has not been clearly established thus far. Therefore, we performed a systematic review and meta-analysis to investigate the association between hyperglycemia and the development of aSAH. We completed a literature search in four databases (PubMed, EMBASE, Cochrane Library, and Web of Science) up to November 1, 2021, including all eligible studies investigating the prognostic value of hyperglycemia in patients with aSAH. We performed a quality assessment of included studies using the Newcastle-Ottawa Quality Assessment Scale. The pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated to assess the association of hyperglycemia in aneurysmal subarachnoid hemorrhage. A total of 35 studies with 11,519 patients were finally included in the meta-analysis. Nineteen studies reported the association between hyperglycemia and poor outcome, 12 studies reported the association between hyperglycemia and all-cause mortality, 7 studies reported the association between hyperglycemia and cerebral vasospasm, and 9 studies reported the association between hyperglycemia and cerebral infarction. The pooled data of these studies suggested that hyperglycemia was significantly associated with poor functional outcomes (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.17-1.42; P < 0.00001; I² = 83%), all-cause mortality (OR, 1.02; 95% CI, 1.01-1.04; P = 0.0006; I² = 89%), cerebral vasospasm (OR, 1.02; 95% CI, 1.01-1.02; P = 0.0002; I² = 35%), and cerebral infarction (OR, 1.16; 95% CI, 1.09-1.23; P < 0.00001; I² = 10%) in aSAH patients. These findings suggested that assessing for hyperglycemia at admission may help clinicians to identify critically ill patients and complete patient stratification early, which may achieve better management and improve the prognosis of patients with aSAH.

In-hospital complication-related risk factors for discharge and 90-day outcomes in patients with aneurysmal subarachnoid hemorrhage after surgical clipping and endovascular coiling: a propensity score-matched analysis

OBJECTIVE

More than 10 years have passed since the two best-known clinical trials of ruptured aneurysms (International Subarachnoid Aneurysm Trial [ISAT] and Barrow Ruptured Aneurysm Trial [BRAT]) indicated that endovascular coiling (EC) was superior to surgical clipping (SC). However, in recent years, the development of surgical techniques has greatly improved; thus, it is necessary to reanalyze the impact of the differences in treatment modalities on the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

The authors retrospectively reviewed all aSAH patients admitted to their institution between January 2015 and December 2020. The functional outcomes at discharge and 90 days after discharge were assessed using the modified Rankin Scale (mRS). In-hospital complications, hospital charges, and risk factors derived from multivariate logistic regression were analyzed in the SC and EC groups after 1:1 propensity score matching (PSM). The area under the receiver operating characteristic curve was used to calculate each independent predictor's prediction ability between treatment groups.

RESULTS

A total of 844 aSAH patients were included. After PSM to control for sex, aneurysm location, Hunt and Hess grade, World Federation of Neurosurgical Societies (WFNS) grade, modified Fisher Scale grade, and current smoking and alcohol abuse status, 329 patients who underwent SC were compared with 329 patients who underwent EC. Patients who underwent SC had higher incidences of unfavorable discharge and 90-day outcomes (46.5% vs 33.1%, p < 0.001; and 19.6% vs 13.8%, p = 0.046, respectively), delayed cerebral ischemia (DCI) (31.3% vs 20.1%, p = 0.001), intracranial infection (20.1% vs 1.2%, p < 0.001), anemia (42.2% vs 17.6%, p < 0.001), hypoproteinemia (46.2% vs 21.6%, p < 0.001), and pneumonia (33.4% vs 24.9%, p = 0.016); but a lower incidence of urinary tract infection (1.2% vs 5.2%, p = 0.004) and lower median hospital charges ($12,285 [IQR $10,399-$15,569] vs $23,656 [IQR $18,816-$30,025], p < 0.001). A positive correlation between the number of in-hospital complications and total hospital charges was indicated in the SC (r = 0.498, p < 0.001) and EC (r = 0.411, p < 0.001) groups. The occurrence of pneumonia and DCI, WFNS grade IV or V, and age were common independent risk factors for unfavorable outcomes at discharge and 90 days after discharge in both treatment modalities.

CONCLUSIONS

EC shows advantages in discharge and 90-day outcomes, in-hospital complications, and the number of risk factors but increases the economic cost on patients during their hospital stay. Severe in-hospital complications such as pneumonia and DCI may have a long-lasting impact on the prognosis of patients.

Characterizing Risk of In-Hospital Mortality Following Subarachnoid Hemorrhage Using Machine Learning: A Retrospective Study

Background

Subarachnoid hemorrhage has a high rate of disability and mortality, and the ability to use existing disease severity scores to estimate the risk of adverse outcomes is limited. Collect relevant information of patients during hospitalization to develop more accurate risk prediction models, using logistic regression (LR) and machine learning (ML) technologies, combined with biochemical information.

Methods

Patient-level data were extracted from MIMIC-IV data. The primary outcome was in-hospital mortality. The models were trained and tested on a data set (ratio 70:30) including age and key past medical history. The recursive feature elimination (RFE) algorithm was used to screen the characteristic variables; then, the ML algorithm was used to analyze and establish the prediction model, and the validation set was used to further verify the effectiveness of the model.

Result

Of the 1,787 patients included in the mimic database, a total of 379 died during hospitalization. Recursive feature abstraction (RFE) selected 20 variables. After simplification, we determined 10 features, including the Glasgow coma score (GCS), glucose, sodium, chloride, SPO₂, bicarbonate, temperature, white blood cell (WBC), heparin use, and sepsis-related organ failure assessment (SOFA) score. The validation set and Delong test showed that the simplified RF model has a high AUC of 0.949, which is not significantly different from the best model. Furthermore, in the DCA curve, the simplified GBM model has relatively higher net benefits. In the subgroup analysis of non-traumatic subarachnoid hemorrhage, the simplified GBM model has a high AUC of 0.955 and relatively higher net benefits.

Conclusions

ML approaches significantly enhance predictive discrimination for mortality following subarachnoid hemorrhage compared to existing illness severity scores and LR. The discriminative ability of these ML models requires validation in external cohorts to establish generalizability.

Cerebral Microdialysis-Based Interventions Targeting Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Delayed cerebral ischemia (DCI), a complication of subarachnoid hemorrhage (SAH), is linked to cerebral vasospasm and associated with poor long-term outcome. We implemented a structured cerebral microdialysis (CMD) based protocol using the lactate/pyruvate ratio (LPR) as an indicator of the cerebral energy metabolic status in the neurocritical care decision making, using an LPR ≥ 30 as a cutoff suggesting an energy metabolic disturbance. We hypothesized that CMD monitoring could contribute to active, protocol-driven therapeutic interventions that may lead to the improved management of patients with SAH.

METHODS

Between 2018 and 2020, 49 invasively monitored patients with SAH, median Glasgow Coma Scale 11 (range 3-15), and World Federation of Neurosurgical Societies scale 4 (range 1-5) on admission receiving CMD were included. We defined a major CMD event as an LPR ≥ 40 for ≥ 2 h and a minor CMD event as an LPR ≥ 30 for ≥ 2 h.

RESULTS

We analyzed 7,223 CMD samples over a median of 6 days (5-8). Eight patients had no CMD events. In 41 patients, 113 minor events were recorded, and in 23 patients 42 major events were recorded. Our local protocols were adhered to in 40 major (95%) and 98 minor events (87%), with an active intervention in 32 (76%) and 71 (63%), respectively. Normalization of energy metabolic status (defined as four consecutive samples with LPR < 30 for minor and LPR < 40 for major events) was seen after 69% of major and 59% of minor events. The incidence of DCI-related infarcts was 10% (five patients), with only two observed in a CMD-monitored brain region.

CONCLUSIONS

Active interventions were initiated in a majority of LPR events based on CMD monitoring. A low DCI incidence was observed, which may be associated with the active interventions. The potential aid of CMD in the clinical decision-making targeting DCI needs confirmation in additional SAH studies.

The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a rare event affecting relatively young patients therefore leading to a high social impact. The management of SAH follows a biphasic course with early brain injuries in the first 72 hours followed by a phase at risk of secondary deterioration due to delayed cerebral ischemia (DCI) in 20 to 30% patients. Cerebral infarction from DCI is the most preventable cause of mortality and morbidity after SAH. DCI prevention, early detection and treatment is therefore advocated. Formerly limited to the occurrence of vasospasm, DCI is now associated with multiple pathophysiological processes involving for instance the macrocirculation, the microcirculation, neurovascular units, and inflammation. Therefore, the therapeutic targets and management strategies are also evolving and are not only focused on proximal vasospasm. In this review, we describe the current knowledge of DCI pathophysiology. We then discuss the diagnosis strategies that may guide physicians at the bedside with a multimodal approach in the unconscious patient. We will present the prevention strategies that have proven efficient as well as future targets and present the therapeutic approach that is currently being developed when a DCI occurs.

Association Between Glycemic Gap and In-hospital Outcomes in Aneurysmal Subarachnoid Hemorrhage

Introduction: Glycemic gap (GG), as determined by the difference between glucose and the hemoglobin A1c (HbA1c)-derived estimated average glucose (eAG), is associated with poor outcomes in various clinical settings. There is a paucity of data describing GG and outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Our main objectives were to evaluate the association of admission glycemic gap (aGG) with in-hospital mortality and with poor composite outcome and to compare aGG's predictive value to admission serum glucose. Secondary outcomes were the associations between aGG and neurologic complications including vasospasm and delayed cerebral ischemia following aSAH.

Methods: We retrospectively reviewed 119 adult patients with aSAH admitted to a single tertiary care neuroscience ICU. Spearman method was used for correlation for non-normality of data. Area under the curve (AUC) for Receiver Operating Characteristic (ROC) curve was used to estimate prediction accuracy of aGG and admission glucose on outcome measures. Multivariable analyses were conducted to assess the value of aGG in predicting in-hospital poor composite outcome and death.

Results: Elevated aGG at or above 30 mg/dL was identified in 79 (66.4%) of patients. Vasospasm was not associated with the elevated aGG. Admission GG correlated with admission serum glucose (r = 0.94, p < 0.01), lactate (r = 0.41, p < 0.01), procalcitonin (r = 0.38, p < 0.01), and Hunt and Hess score (r = 0.51, p < 0.01), but not with HbA1c (r = 0.02, p = 0.82). Compared to admission glucose, aGG had a statistically significantly improved accuracy in predicting inpatient mortality (AUC mean ± SEM: 0.77 ± 0.05 vs. 0.72 ± 0.06, p = 0.03) and trended toward statistically improved accuracy in predicting poor composite outcome (AUC: 0.69 ± 0.05 vs. 0.66 ± 0.05, p = 0.07). When controlling for aSAH severity, aGG was not independently associated with delayed cerebral ischemia, poor composite outcome, and in-hospital mortality.

Conclusion: Admission GG was not independently associated with in-hospital mortality or poor outcome in a population of aSAH. An aGG ≥30 mg/dL was common in our population, and further study is needed to fully understand the clinical importance of this biomarker.

Increase in Brain Volume After Aneurysmal Subarachnoid Hemorrhage Leads to Unfavorable Outcome: A Retrospective Study Quantified by CT Scan

Background and Purpose: Primary brain swelling occurs in aneurysmal subarachnoid hemorrhage (aSAH) patients. The absence of a dynamic quantitative method restricts further study of primary brain swelling. This study compared differences in the change rate of brain volume (CRBV) between patients with and without primary brain swelling in the early stage of aSAH. Moreover, the relationship between CRBV and clinical outcomes was evaluated.

Methods: Patients hospitalized within 24 h after aSAH were included in this retrospective study. Utilizing a qualitative standard established before the study to recognize primary brain swelling through brain CT after aSAH, clinical outcomes after 3 months of SAH were evaluated with a modified Rankin scale (mRS). The brain volume (BV) of each patient was calculated with a semiautomatic threshold algorithm of 3D-slicer, and the change in brain volume (CIBV) was obtained by subtracting the two extreme values (CIBV = BV_max – BV_min). The CRBV was obtained by CIBV/BV_min × 100%. The CRBV values that predicted unfavorable prognoses were estimated.

Results: In total, 130 subjects were enrolled in the study. The mean CRBV in the non-swelling group and swelling group were 4.37% (±4.77) and 11.87% (±6.84), respectively (p < 0.05). CRBV was positively correlated with the length of hospital stay, blood in the ambient cistern, blood in the lateral ventricle, and lateral ventricular volume (Spearman ρ = 0.334; p < 0.001; Pearson ρ = 0.269, p = 0.002; Pearson ρ = 0.278, p = 0.001; Pearson ρ = 0.233, p = 0.008, respectively). Analysis of variance showed significant differences in CIBV, CRBV, blood in the ambient cistern, blood in the lateral ventricle, and lateral ventricular volume among varying modified Fisher scale (mFisher), with higher admission mFisher scale, indicating larger values of these variables. After adjusting for risk factors, the model showed that for every 1% increase in the CRBV, the probability of poor clinical prognosis increased by a factor of 1.236 (95% CI = 1.056–1.446). In the stratified analysis, the odds of worse clinical outcomes increased with increases in the CRBV. Receiver operating characteristic curve analysis showed that HH grade, mFisher scale, and score of CRBV (SCRBV) had diagnostic performance for predicting unfavorable clinical outcomes.

Conclusion: Primary brain swelling increases brain volume after aSAH. The CRBV quantified by 3D-Slicer can be used as a volumetric representation of the degree of brain swelling. A larger CRBV in the early stage of aSAH is associated with poor prognosis. The CRBV can be used as a neuroimaging biomarker of early brain injury after bleeding and may be an effective predictor of patients' clinical prognoses.

Methodological quality of multivariate prognostic models for intracranial haemorrhages in intensive care units: a systematic review

OBJECTIVES

Patients with severe spontaneous intracranial haemorrhages, managed in intensive care units, face ethical issues regarding the difficulty of anticipating their recovery. Prognostic tools help clinicians in counselling patients and relatives and guide therapeutic decisions. We aimed to methodologically assess prognostic tools for functional outcomes in severe spontaneous intracranial haemorrhages.

DATA SOURCES

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations, we conducted a systematic review querying Medline, Embase, Web of Science, and the Cochrane in January 2020.

STUDY SELECTION

We included development or validation of multivariate prognostic models for severe intracerebral or subarachnoid haemorrhage.

DATA EXTRACTION

We evaluated the articles following the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies and Transparent Reporting of multivariable prediction model for Individual Prognosis Or Diagnosis statements to assess the tools' methodological reporting.

RESULTS

Of the 6149 references retrieved, we identified 85 articles eligible. We discarded 43 articles due to the absence of prognostic performance or predictor selection. Among the 42 articles included, 22 did not validate models, 6 developed and validated models and 14 only externally validated models. When adding 11 articles comparing developed models to existing ones, 25 articles externally validated models. We identified methodological pitfalls, notably the lack of adequate validations or insufficient performance levels. We finally retained three scores predicting mortality and unfavourable outcomes: the IntraCerebral Haemorrhages (ICH) score and the max-ICH score for intracerebral haemorrhages, the SubArachnoid Haemorrhage International Trialists score for subarachnoid haemorrhages.

CONCLUSIONS

Although prognostic studies on intracranial haemorrhages abound in the literature, they lack methodological robustness or show incomplete reporting. Rather than developing new scores, future authors should focus on externally validating and updating existing scores with large and recent cohorts.

Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) as a radiographic marker of clinically relevant intracranial hypertension and unfavorable outcome after subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The severity of early brain edema (EBE) after aneurysm rupture was reported to be strongly associated with the risk of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Using the recently developed Subarachnoid Hemorrhage Early Brain Edema Score (SEBES), we analyzed the predictors of EBE and its impact on complications related to intracranial pressure (ICP) increase after SAH and on poor outcome.

METHODS

All consecutive SAH cases treated between January 2003 and June 2016 with assessable SEBES were included (n = 745). Data on demographic characteristics, medical history, initial severity of SAH, need for conservative ICP treatment and decompressive craniectomy, occurrence of cerebral infarctions and unfavorable outcome at 6 months (modified Rankin scale score > 2) were collected. Univariable and multivariable analyses were performed.

RESULTS

Younger age (<55 years; adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI] 2.28-4.38), female sex (aOR 1.64, 95% CI 1.16-2.31), poor initial clinical condition (World Federation of Neurosurgical Societies score 4-5; aOR 1.74, 95% CI 1.23-2.46), presence of intracerebral hemorrhage (aOR 1.63, 95% CI 1.12-2.36), hypothyroidism (aOR 0.60, 95% CI 0.37-0.98) and renal comorbidity (aOR 0.29, 95% CI 0.11-0.78) were independently associated with SEBES (scores 3-4). There was an independent association between SEBES 3-4 and the need for conservative ICP treatment (aOR 2.43, 95% CI 1.73-3.42), decompressive craniectomy (aOR 2.68, 95% CI 1.84-3.89), development of cerebral infarcts (aOR 2.24, 95% CI 1.53-3.29) and unfavorable outcome (aOR 1.48, 95% CI 1.0-2.17).

CONCLUSIONS

SEBES is a reliable predictor of ICP-related complications and poor outcome of SAH. Our findings highlight the need for further research of the impact of patients' demographic characteristics and comorbidities on the severity of EBE after SAH.

Comorbidities and Medical Complications in Hospitalized Subarachnoid Hemorrhage Patients

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) remains a devastating condition with a case fatality of 36% at 30 days. Risk factors for mortality in SAH patients include patient demographics and the severity of the neurological injury. Pre-existing conditions and non-neurological medical complications occurring during the index hospitalization are also risk factors for mortality in SAH. The magnitude of the effect on mortality of pre-existing conditions and medical complications, however, is less well understood. In this study, we aim to determine the effect of pre-existing conditions and medical complications on SAH mortality.

METHODS

For a 25% random sample of the Greater Montreal Region, we used discharge abstracts, physician billings, and death certificate records, to identify adult patients with a new diagnosis of non-traumatic SAH who underwent cerebral angiography or surgical clipping of an aneurysm between 1997 and 2014.

RESULTS

The one-year mortality rate was 14.76% (94/637). Having ≥3 pre-existing conditions was associated with increased one-year mortality OR 3.74, 95% CI [1.25, 9.57]. Having 2, or ≥3 medical complications was associated with increased one-year mortality OR, 2.42 [95% CI 1.25-4.69] and OR, 2.69 [95% CI 1.43-5.07], respectively. Sepsis, respiratory failure, and cardiac arrhythmias were associated with increased one-year mortality. Having 1, 2, or ≥3 pre-existing conditions was associated with increased odds of having medical complications in hospital.

CONCLUSIONS

Pre-existing conditions and in-hospital non-neurological medical complications are associated with increased one-year mortality in SAH. Pre-existing conditions are associated with increased medical complications.

Glycemic indices predict outcomes after aneurysmal subarachnoid hemorrhage: a retrospective single center comparative analysis

Although hyperglycemia is associated with worse outcomes after aneurysmal subarachnoid hemorrhage (aSAH), there is no consensus on the optimal glucose control metric, acceptable in-hospital glucose ranges, or suitable insulin regimens in this population. In this single-center retrospective cohort study of aSAH patients, admission glucose, and hospital glucose mean (MHG), minimum (MinG), maximum (MaxG), and variability were compared. Primary endpoints (mortality, complications, and vasospasm) were assessed using multivariate logistic regressions. Of the 217 patients included, complications occurred in 83 (38.2%), 124 (57.1%) had vasospasm, and 41 (18.9%) died. MHG was independently associated with (p < 0.001) mortality, MaxG (p = 0.017) with complications, and lower MinG (p = 0.015) with vasospasm. Patients with MHG ≥ 140 mg/dL had 10 × increased odds of death [odds ratio (OR) = 10.3; 95% CI 4.6–21.5; p < 0.0001] while those with MinG ≤ 90 mg/dL had nearly 2× increased odds of vasospasm (OR = 1.8; 95% CI 1.01–3.21; p = 0.0422). While inpatient insulin was associated with increased complications and provided no mortality benefit, among those with MHG ≥ 140 mg/dL insulin therapy resulted in lower mortality (OR = 0.3; 95% CI 0.1–0.9; p = 0.0358), but no increased complication risk. While elevated MHG and MaxG are highly associated with poorer outcomes after aSAH, lower MinG is associated with increased vasospasm risk. Future trials should consider initiating insulin therapy based on MHG rather than other hyperglycemia measures.

Lung Protective Ventilation in Brain-Injured Patients: Low Tidal Volumes or Airway Pressure Release Ventilation?

The optimal mode of mechanical ventilation for lung protection is unknown in brain-injured patients as this population is excluded from large studies of lung protective mechanical ventilation. Survey results suggest that low tidal volume (LTV) ventilation is the favored mode likely due to the success of LTV in other patient populations. Airway pressure release ventilation (APRV) is an alternative mode of mechanical ventilation that may offer several benefits over LTV in this patient population. APRV is an inverse-ratio, pressure-controlled mode of mechanical ventilation that utilizes a higher mean airway pressure compared with LTV. This narrative review compares both modes of mechanical ventilation and their consequences in brain-injured patients. Fears that APRV may raise intracranial pressure by virtue of a higher mean airway pressure are not substantiated by the available evidence. Primarily by virtue of spontaneous breathing, APRV often results in improvement in systemic hemodynamics and thereby improvement in cerebral perfusion pressure. Compared with LTV, sedation requirements are lessened by APRV allowing for more accurate neuromonitoring. APRV also uses an open loop system supporting clearance of secretions throughout the respiratory cycle. Additionally, APRV avoids hypercapnic acidosis and oxygen toxicity that may be especially deleterious to the injured brain. Although high-level evidence is lacking that one mode of mechanical ventilation is superior to another in brain-injured patients, several aspects of APRV make it an appealing mode for select brain-injured patients.

Systemic Severity and Organ Dysfunction in Subarachnoid Hemorrhage: A Large Retrospective Multicenter Cohort Study

BACKGROUND AND PURPOSE

Acute physiologic derangements and multiple organ dysfunction are common after subarachnoid hemorrhage. We aimed to evaluate the simplified acute physiology score 3 (SAPS-3) and the sequential organ failure assessment (SOFA) scores for the prediction of in-hospital mortality in a large multicenter cohort of SAH patients.

METHODS

This was a retrospective analysis of prospectively collected data from 45 ICUs in Brazil, during 2014 and 2015. Patients admitted with non-traumatic subarachnoid hemorrhage (SAH) were included. Clinical and outcome data were retrieved from an electronic ICU quality registry. SAPS-3 and SOFA scores, without the neurological components (i.e., nSAPS-3 and nSOFA, respectively) were recorded, as well as the World Federation of Neurological Surgeons (WFNS) scale. We used multilevel logistic regression analysis to identify factors associated with in-hospital mortality. We evaluated performance using the area under the receiver operating characteristic curve (AUROC), as well as calibration belts and precision-recall plots.

RESULTS

The study included 997 patients, from which 426 (43%) had poor clinical grade (WFNS 4 or 5) and in-hospital mortality was 34%. Median nSAPS-3 and nSOFA score at admission were 46 (IQR: 38-55) and 2 (0-5), respectively. Non-survivors were older, had higher nSAPS-3 and nSOFA, and more often poor grade. After adjustment for age, poor grade and withdrawal of life sustaining therapies, multivariable analysis identified nSAPS-3 and nSOFA score as independent clinical predictors of in-hospital mortality. The AUROC curve that included nSAPS-3 and nSOFA scores significantly improved the already good discrimination and calibration of age and WFNS to predict in-hospital mortality (AUROC: 0.89 for the full final model vs. 0.85 for age and WFNS; P < 0.0001).

CONCLUSIONS

nSAPS-3 and nSOFA scores were independently associated with in-hospital mortality after SAH. The addition of these scores improved early prediction of hospital mortality in our cohort and should be integrated to other specific prognostic indices in the early assessment of SAH.

Impact of hyperglycemia on neuronal apoptosis after subarachnoid hemorrhage in rodent brain: An experimental research

BACKGROUND

Hyperglycemia, a derangement after subarachnoid hemorrhage (SAH), is known to be associated with unfavorable outcomes. Whether the connection between hyperglycemia and poor prognosis results from severe neuronal apoptosis is unknown, and we aim at investigating their relationship.

MATERIAL AND METHODS

Streptozotocin (STZ) was administrated to trigger hyperglycemia before SAH induction in Sprague-Dawley rats that were assigned to one of four groups: control, SAH only, hyperglycemia only, and SAH with hyperglycemia. The severity of neuronal apoptosis was analyzed by terminal deoxynucleotidyl transferase-mediated dUTP nickend labelling (TUNEL) staining of cerebral cortex.

RESULTS

When subjected to SAH, hyperglycemic animals had worse neurobehavioral functions than normoglycemic ones. Hyperglycemia-exacerbated apoptosis was evident by greater increases in cleaved caspase-3 expression and TUNEL-positive cell density in the SAH with hyperglycemia group than those in the SAH only group, whereas there was no significant difference in cleaved caspase-9 expression and Bax/Bcl-2 ratio between the two groups. Furthermore, there was a remarkable decrease in the ratio of phosphorylated extracellular regulated kinase (ERK)/total ERK in the hyperglycemic rats after SAH.

CONCLUSION

Hyperglycemia aggravated neuronal apoptosis after SAH and was associated with impaired neurological outcomes. Activation of the extrinsic caspase cascade through the ERK signal pathway may contribute to hyperglycemia-mediated apoptosis.

A Model for Prediction of In-Hospital Mortality in Patients with Subarachnoid Hemorrhage

BACKGROUND

Despite being a rare cause of stroke, spontaneous subarachnoid hemorrhage (SAH) is associated with high mortality rates. The prediction models that are currently being used on SAH patients are heterogeneous, and few address premature mortality. The aim of this study was to develop a mortality risk stratification score for SAH.

METHODS

A retrospective study was carried out with 536 patients diagnosed with SAH who had been admitted to the intensive care unit (ICU) at the University Hospital Complex of A Coruña (Spain) between 2003 and 2013. A multivariate logistic regression model was developed to predict the likelihood of in-hospital mortality, adjusting it exclusively for variables present on admission. A predictive equation of in-hospital mortality was then computed based on the model's coefficients, along with a points-based risk-scoring system. Its discrimination ability was also tested based on the area under the receiver operating characteristics curve and compared with previously developed scores.

RESULTS

The mean age of the patients included in this study was 56.9 ± 14.1 years. Most of these patients (73.9%) had been diagnosed with aneurysmal SAH. Their median length of stay was 7 days in the ICU and 20 days in the general hospital ward, with an overall in-hospital mortality rate of 28.5%. The developed scales included the following admission variables independently associated with in-hospital mortality: coma at onset [odds ratio (OR) = 1.87; p = 0.028], Fisher scale score of 3-4 (OR = 2.27; p = 0.032), Acute Physiology and Chronic Health Evaluation II (APACHE II) score within the first 24 h (OR = 1.10; p < 0.001), and total Sequential Organ Failure Assessment (SOFA) score on day 0 (OR = 1.19; p = 0.004). Our predictive equation demonstrated better discrimination [area under the curve (AUC) = 0.835] (bootstrap-corrected AUC = 0.831) and calibration properties than those of the HAIR scale (AUC = 0.771; p ≤ 0.001) and the Functional Recovery Expected after Subarachnoid Hemorrhage scale (AUC = 0.814; p = 0.154).

CONCLUSIONS

In addition to the conventional risk factors for in-hospital mortality, in our study, mortality was associated with the presence of coma at onset of the condition, the physiological variables assessed by means of the APACHE II scale within the first 24 h, and the total SOFA score on day 0. A simple prediction model of mortality was developed with novel parameters assessed on admission, which also assessed organ failure and did not require a previous etiological diagnosis.

Gap Analysis Regarding Prognostication in Neurocritical Care: A Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society

Background/Objective

Prognostication is a routine part of the delivery of neurocritical care for most patients with acute neurocritical illnesses. Numerous prognostic models exist for many different conditions. However, there are concerns about significant gaps in knowledge regarding optimal methods of prognostication.

Methods

As part of the Arbeitstagung NeuroIntensivMedizin meeting in February 2018 in Würzburg, Germany, a joint session on prognostication was held between the German NeuroIntensive Care Society and the Neurocritical Care Society. The purpose of this session was to provide presentations and open discussion regarding existing prognostic models for eight common neurocritical care conditions (aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, traumatic spinal cord injury, status epilepticus, Guillain–Barré Syndrome, and global cerebral ischemia from cardiac arrest). The goal was to develop a qualitative gap analysis regarding prognostication that could help inform a future framework for clinical studies and guidelines.

Results

Prognostic models exist for all of the conditions presented. However, there are significant gaps in prognostication in each condition. Furthermore, several themes emerged that crossed across several or all diseases presented. Specifically, the self-fulfilling prophecy, lack of accounting for medical comorbidities, and absence of integration of in-hospital care parameters were identified as major gaps in most prognostic models.

Conclusions

Prognostication in neurocritical care is important, and current prognostic models are limited. This gap analysis provides a summary assessment of issues that could be addressed in future studies and evidence-based guidelines in order to improve the process of prognostication.

Early Transcranial Doppler Evaluation of Cerebral Autoregulation Independently Predicts Functional Outcome After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Cerebral autoregulation (CA) impairment after aneurysmal subarachnoid hemorrhage (SAH) has been associated with delayed cerebral ischemia and an unfavorable outcome. We investigated whether the early transient hyperemic response test (THRT), a transcranial Doppler (TCD)-based CA evaluation method, can predict functional outcome 6 months after aneurysmal SAH.

METHODS

This is a prospective observational study of all aneurysmal SAH patients consecutively admitted to a single center between January 2016 and February 2017. CA was evaluated within 72 h of hemorrhage by THRT, which describes the changes in cerebral blood flow velocity after a brief compression of the ipsilateral common carotid artery. CA was considered to be preserved when an increase ≥ 9% of baseline systolic velocity was present. According to the modified Rankin Scale (mRS: 4-6), the primary outcome was unfavorable 6 months after hemorrhage. Secondary outcomes included cerebral infarction, vasospasm on TCD, and an unfavorable outcome at hospital discharge.

RESULTS

Forty patients were included (mean age = 54 ± 12 years, 70% females). CA was impaired in 19 patients (47.5%) and preserved in 21 (52.5%). Impaired CA patients were older (59 ± 13 vs. 50 ± 9, p = 0.012), showed worse neurological conditions (Hunt&Hess 4 or 5-47.4% vs. 9.5%, p = 0.012), and clinical initial condition (APACHE II physiological score-12 [5.57-13] vs. 3.5 [3-5], p = 0.001). Fourteen patients in the impaired CA group and one patient in the preserved CA group progressed to an unfavorable outcome (73.7% vs. 4.7%, p = 0.0001). The impaired CA group more frequently developed cerebral infarction than the preserved CA group (36.8% vs. 0%, p = 0.003, respectively). After multivariate analysis, impaired CA (OR 5.15 95% CI 1.43-51.99, p = 0.033) and the APACHE II physiological score (OR 1.67, 95% CI 1.01-2.76, p = 0.046) were independently associated with an unfavorable outcome.

CONCLUSIONS

Early CA impairment detected by TCD and admission APACHE II physiological score independently predicted an unfavorable outcome after SAH.

Significance and Diagnostic Accuracy of Early S100B Serum Concentration after Aneurysmal Subarachnoid Hemorrhage

Background: Early brain injuries (EBI) are one of the most important causes of morbidity and mortality after subarachnoid hemorrhage. At admission, a third of patients are unconscious (spontaneously or sedated) and EBI consequences are not evaluable. To date, it is unclear who will still be comatose (with severe EBI) and who will recover (with less severe EBI) once the aneurysm is treated and sedation withdrawn. The objective of the present study was to determine the diagnostic accuracy of S100B levels at hospital admission to identify patients with severe neurological consequences of EBI. Methods: Patients were consecutively included in this prospective blinded observational study. A motor component of the Glasgow coma score under 6 on day 3 was used to define patients with severe neurological consequences of EBI. Results: A total of 81 patients were included: 25 patients were unconscious at admission, 68 were treated by coiling. On day 3, 12 patients had severe consequences of EBI. A maximal S100B value between admission and day 1 had an area under the receiver operating characteristic curve (AUC) of 86.7% to predict severe EBI consequences. In patients with impaired consciousness at admission, the AUC was 88.2%. Conclusion: Early S100B seems to have a good diagnostic value to predict severe EBI. Before claiming the usefulness of S100B as a surrogate marker of EBI severity to start earlier multimodal monitoring, these results must be confirmed in an independent validation cohort.

Hyperbaric oxygen therapy prevents subarachnoid hemorrhage-induced apoptosis and impaired contractility of the rabbit bladder

AIM

To explore the effects of experimental subarachnoid hemorrhage (SAH) on rabbit urinary bladder and to assess the potential protective effects of hyperbaric oxygen therapy (HBOT).

METHODS

A total of 15 male New Zealand white rabbits were divided randomly to one of three groups: group I was spared as the control group (n = 5), group II was exposed to SAH, received no treatment, and acted as the SAH group (n = 5) and group III was exposed to SAH and received five sessions of HBOT (started 12 hours after SAH induction and was given twice daily for the first 2 days and once on the third day) and acted as the treatment group (n = 5). At 72 hours after the SAH induction, bladders from all animals were removed for in vitro organ bath experiments and biochemical analyses.

RESULTS

İsometric tension studies revealed that compared to group I, the contractile responses of the strips to carbachol in group II were significantly decreased whereas HBOT restored the contractile responses (P < .05). Caspase-3 and nitric oxide synthase (NOS) activities of bladder tissues were significantly increased in group II when compared with group I, whereas caspase-3 and NOS activities were significantly decreased in the tissues of group III (P < .01).

CONCLUSIONS

Subarachnoid hemorrhage stimulates apoptosis of the rabbit bladder and impairs the contractile response of the rabbit bladder to carbachol. HBOT creates a protective effect in rabbit bladder tissues and restores SAH-induced changes.

Enhanced Renal Clearance in Patients With Hemorrhagic Stroke

OBJECTIVES

To evaluate enhanced renal clearance over time in patients with aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage via measured creatinine clearance and to compare measured creatinine clearance to creatinine clearance calculated by the Cockcroft-Gault equation and estimated glomerular filtration rate calculated by the Modification of Diet in Renal Diseases equation.

DESIGN

Prospective, observational study.

SETTING

Neurosciences ICU in a tertiary care academic medical center.

PATIENTS

Study participants had an admission diagnosis of aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage, an expected neurosciences ICU length of stay greater than 48 hours, no evidence of renal dysfunction (admission serum creatinine < 1.5 mg/dL), and no history of chronic kidney disease.

INTERVENTIONS

Eight-hour urine collections to measure creatinine clearance were collected daily as the primary method of measuring renal function. Creatinine clearance was also calculated using the Cockcroft-Gault equation and estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Enhanced renal clearance was defined as a measured creatinine clearance greater than the calculated creatinine clearance via Cockcroft-Gault and estimated glomerular filtration rate via Modification of Diet in Renal Disease. Augmented renal clearance was defined by a measured creatinine clearance greater than or equal to 130 mL/min/1.73 m. Relevant demographic, clinical, and outcome data were recorded.

MEASUREMENTS AND MAIN RESULTS

Fifty aneurysmal subarachnoid hemorrhage patients and 30 intracerebral hemorrhage patients were enrolled, contributing 590 individual measurements. Patients with aneurysmal subarachnoid hemorrhage had a higher mean measured creatinine clearance compared with the mean calculated creatinine clearance based on the Cockcroft-Gault equation (147.9 ± 50.2 vs 109.1 ± 32.7 mL/min/1.73 m; p < 0.0001) and higher mean measured creatinine clearance compared with the mean calculated estimated glomerular filtration rate based on the Modification of Diet in Renal Disease equation (147.9 ± 50.2 vs 126.0 ± 41.9 mL/min/1.73 m; p = 0.04). Ninety-four percent of participants with aneurysmal subarachnoid hemorrhage experienced augmented renal clearance on at least 1 day. In patients with intracerebral hemorrhage, there was a higher mean measured creatinine clearance over the study period compared with the mean calculated creatinine clearance (119.5 ± 57.2 vs 77.8 ± 27.6 mL/min/1.73 m; p < 0.0001) and higher mean measured creatinine clearance compared with the mean calculated estimated glomerular filtration rate based on the Modification of Diet in Renal Disease equation (119.5 ± 57.2 vs 93.0.0 ± 32.8 mL/min/1.73 m; p = 0.02). Fifty percent of participants with intracerebral hemorrhage experienced augmented renal clearance on at least 1 day.

CONCLUSIONS

A substantial group of patients with aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage experienced enhanced renal clearance, which may be otherwise unknown to clinicians. Enhanced renal clearance may lead to increased renal solute elimination over what is expected, resulting in subtherapeutic renally eliminated drug concentrations. This may result in underexposure to critical medications, leading to treatment failure and other medical complications.

Prediction of Outcome After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose- Early prediction of clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH) is still lacking accuracy. In this observational cohort study, we aimed to develop and validate an accurate bedside prediction model for clinical outcome after aSAH, to aid decision-making at an early stage. Methods- For the development of the prediction model, a prospectively kept single-center cohort of 1215 aSAH patients, admitted between 1998 and 2014, was used. For temporal validation, a prospective cohort of 224 consecutive aSAH patients from the same center, admitted between 2015 and 2017, was used. External validation was performed using the ISAT (International Subarachnoid Aneurysm Trial) database (2143 patients). Primary outcome measure was poor functional outcome 2 months after aSAH, defined as modified Rankin Scale score 4-6. The model was constructed using multivariate regression analyses. Performance of the model was examined in terms of discrimination and calibration. Results- The final model included 4 predictors independently associated with poor outcome after 2 months: age, World Federation of Neurosurgical Societies grade after resuscitation, aneurysm size, and Fisher grade. Temporal validation showed high discrimination (area under the receiver operating characteristic curve, 0.90; 95% CI, 0.85-0.94), external validation showed fair to good discrimination (area under the receiver operating characteristic curve, 0.73; 95% CI, 0.70-0.76). The model showed satisfactory calibration in both validation cohorts. The SAFIRE grading scale was derived from the final model: size of the aneurysm, age, Fisher grade, world federation of neurosurgical societies after resuscitation. Conclusions- The SAFIRE grading scale is an accurate, generalizable, and easily applicable model for early prediction of clinical outcome after aSAH.

Enhanced renal clearance and impact on vancomycin pharmacokinetic parameters in patients with hemorrhagic stroke

BACKGROUND

The majority of patients with hemorrhagic stroke experience enhanced renal clearance or augmented renal clearance (ARC). The purpose of this study was to determine the impact of enhanced renal clearance or ARC on vancomycin pharmacokinetic (PK) parameters.

METHODS

This was a post hoc analysis of a prospective study of adult patients with aneurysmal subarachnoid hemorrhage (aSAH) or intracerebral hemorrhage (ICH) admitted to the neurosciences intensive care unit who received vancomycin. Creatinine clearance (CrCl) was measured and also estimated using the Cockcroft-Gault equation. Predicted PK parameters were compared with calculated PK parameters using serum peak and trough concentrations.

RESULTS

Seventeen hemorrhagic stroke patients met inclusion criteria. All patients experienced enhanced renal clearance on the day that the vancomycin concentrations were obtained, and 12 patients (71%) experienced ARC. The mean calculated elimination rate constant was significantly higher than the predicted value (0.141 ± 0.02 vs. 0.087 ± 0.01 h-1; p = 0.004) and the mean calculated half-life was significantly lower than the predicted half-life (6.5 ± 0.9 vs. 8.7 ± 0.6 h; p = 0.03).

CONCLUSIONS

Patients with hemorrhagic stroke and enhanced renal clearance displayed PK alterations favoring an increased elimination of vancomycin than expected. This may result in underexposure to vancomycin, leading to treatment failure.

Thick and Diffuse Subarachnoid Blood as a Treatment Effect Modifier of Clazosentan After Subarachnoid Hemorrhage

Background and Purpose- Clazosentan, an endothelin receptor antagonist, has been shown to reduce angiographic vasospasm and vasospasm-related morbidity after aneurysmal subarachnoid hemorrhage (SAH), although no effect on long-term functional outcome has been demonstrated. Thick clot on initial computed tomography is associated with an increased risk of vasospasm and delayed cerebral ischemia. In this post hoc analysis, we hypothesized that use of clazosentan in this subpopulation would provide stronger benefit. Methods- We analyzed SAH patients enrolled in the CONSCIOUS-2 and CONSCIOUS-3 studies (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) and compared the effects of clazosentan 5 mg/h, 15 mg/h, and placebo starting the day after aneurysm repair. The analysis was performed separately based on the presence or absence of thick (≥4 mm) and diffuse (≥3 cisterns) SAH on admission computed tomography. The primary composite end point was all-cause mortality and vasospasm-related morbidity at 6 weeks, and the main secondary end point was the extended Glasgow Outcome Scale at 3 months, adjusted for admission clinical grade. Results- Of 1718 randomized patients, 919 (53%) had thick and diffuse SAH. The primary composite end point in this group occurred in 36% of placebo-treated patients (n=294), 30% patients treated with clazosentan 5 mg/h (n=514; relative risk, 0.82; 95% CI, 0.67-0.99), and 19% patients treated with clazosentan 15 mg/h (n=111; relative risk, 0.54; 95% CI, 0.36-0.80). Despite this, death or poor functional outcome (Glasgow Outcome Scale ≤4) occurred in 33% of placebo-treated patients, 34% of patients treated with clazosentan 5 mg/h (relative risk 1.02; 95% CI, 0.84-1.23), and 35% of patients treated with clazosentan 15 mg/h (relative risk 1.14; 95% CI, 0.88-1.48). Conclusions- In an enriched population with thick and diffuse SAH, clazosentan at a dose of 5 and 15 mg/h was able to significantly reduce vasospasm-related morbidity in a dose-dependent manner. The absence of an effect on long-term functional status likely reflects the complexity and multiplicity of factors that contribute to poor outcome after SAH. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00558311; NCT00940095.

Early Prognostication of 1-Year Outcome After Subarachnoid Hemorrhage: The FRESH Score Validation

BACKGROUND AND AIM

The FRESH score is a tool to prognosticate long-term outcomes after spontaneous subarachnoid hemorrhage (SAH). Here, for the first time, we aimed to externally validate the disability part of FRESH using its original four score variables.

METHODS

A total of 107 patients with SAH were prospectively enrolled in the Yale Acute Brain Injury Biorepository between September 2014 and January 2018. 12-month functional outcome was recorded prospectively by trained study investigators using the modified Rankin Scale (mRS). FRESH-scores were calculated retrospectively using the original score variables. We used R² statistics to assess goodness of fit, and the area under the receiver operating characteristic curve (AUC) to assess ability of the score to discriminate between favorable and unfavorable (defined as mRS 4-6) outcome.

RESULTS

We identified 86 patients with SAH with complete 1-year follow-up data. Mean age was 60 years, 60% were women. An aneurysmal bleeding source was found in 71% of patients. 80% underwent aneurysm coiling, and 5% clipping. Sixteen percent of patients were considered high grade on admission (Hunt&Hess score 4 or 5). Discrimination of the FRESH score between favorable and unfavorable outcome was high (AUC 90.8%, confidence interval 81.9%-96.5%). Nagelkerke's (.54) and Cox&Snell's R² (.35) indicated satisfactory fit. Exclusion of patients without aneurysmal etiology of SAH did not significantly alter model performance.

CONCLUSIONS

FRESH, a prognostication score of long-term outcomes in patients with SAH showed excellent score performance in this external validation. FRESH may guide the efficient use of hospital resources, family discussions, and stratification of patients in future randomized controlled trials.

The use of SAPS 3, SOFA, and Glasgow Coma Scale to predict mortality in patients with subarachnoid hemorrhage: A retrospective cohort study

Guidelines for patients with subarachnoid hemorrhage (SAH) management and several grading systems or prognostic indices have been used not only to improve the quality of care but to predict also the outcome of these patients. Among them, the gold standards Fisher radiological grading scale, Hunt-Hess and the World Federation of Neurological Surgeons (WFNS) are the most employed. The objective of this study is to compare the predictive values of simplified acute physiology score (SAPS) 3, sequential organ failure assessment (SOFA), and Glasgow Coma Scale (GCS) in the outcome of patients with aneurysmal SAH.Fifty-one SAH patients (33% males and 67% females; mean age of 54.1 ± 10.3 years) admitted to the intensive care units (ICU) in the post-operative phase were retrospectively studied. The patients were divided into survivors (n=37) and nonsurvivors (n = 14). SAPS 3, Fischer scale, WFNS, SOFA, and GCS were recorded on ICU admission (day 1 - D1), and 72-hours (day 3 - D3) SOFA, and GCS. The capability of each index SAPS 3, SOFA, and GCS (D1 and D3) to predict mortality was analyzed by receiver operating characteristic (ROC) curves. The area under the ROC curve (AUC) and the respective confidence interval (CI) were used to measure the index accuracy. The level of significance was set at P < .05.The mean SAPS 3, SOFA, and GCS on D1 were 13.5 ± 12.7, 3.1 ± 2.4, and 13.7 ± 2.8 for survivors and 32.5 ± 28.0, 5.6 ± 4.9, and 13.5 ± 1.9 for nonsurvivors, respectively. The AUC and 95% CI for SAPS 3, SOFA, and GCS on D1 were 0.735 (0.592-0.848), 0.623 (0.476-0.754), 0.565 (0.419-0.703), respectively. The AUC and 95% CI for SOFA and GCS on D3 were 0.768 (0.629-0.875) and 0.708 (0.563-0.826), respectively. The overall mortality was 37.8%.Even though SAPS 3 and Fischer scale predicted mortality better on admission (D1), both indices SOFA and GCS performed similarly to predict outcome in SAH patients on D3.

Serum Lactic Acid Following Aneurysmal Subarachnoid Hemorrhage Is a Marker of Disease Severity but Is Not Associated With Hospital Outcomes

Background: Following aneurysmal subarachnoid hemorrhage, peripherally-drawn lactic acid has been associated with poor outcomes; however, its clinical significance is unknown. We investigated admission factors and patient outcomes associated with serum lactic acid in this population.

Methods: This was a retrospective observational study of 105 consecutive patients with serum lactate collected within 24 h of admission. Primary objectives were to determine the incidence of admission lactic acidemia, and factors positively and negatively associated with lactate levels. We also sought to determine if admission lactic acidemia was associated with patient outcomes, including vasospasm, delayed cerebral ischemia, mortality, and discharge disposition.

Results: Admission serum lactic acid was elevated in 56 patients (53% of the cohort). Levels were positively associated with Hunt & Hess and modified Fisher grade, glucose, troponin I and white blood cell counts, and negatively associated with GCS and ventilator-free days. Admission lactate was not associated with the development of vasospasm or delayed cerebral ischemia. Patients with elevated lactic acid more often died during hospitalization, and less often were discharged home. After adjusting for other predictors of poor outcome, the adjusted odds of inpatient mortality (OR 0.97, 95% CI 0.79–1.20; p = 0.80) and discharge to home (OR 1.00, 95% CI 0.80–1.26; p = 0.97) was not associated with admission lactic acid.

Conclusions: Early serum lactic acid elevation is common following aneurysmal subarachnoid hemorrhage and is associated with the clinical and radiographic grade of hemorrhage. Levels did not independently predict short-term outcomes when adjusted for established predictors of poor outcome. Further study is needed to determine the clinical significance of peripherally-drawn lactic acid in aneurysmal subarachnoid hemorrhage.

Diagnostic accuracy of quantitative EEG to detect delayed cerebral ischemia after subarachnoid hemorrhage: A preliminary study

OBJECTIVE

Delayed cerebral ischemia (DCI) is the most important and preventable morbidity cause after subarachnoid hemorrhage (SAH). Therefore, DCI early detection is a major challenge. Yet, neurological examination can be unreliable in poor grade SAH patients. EEG provides information from most superficial cortical area, with ischemia-related changes. This study aims at defining an alpha-theta/delta (AT/D) ratio decrease thresholds to detect DCI.

METHODS

We used EEG with a montage matching vascular territories (right and left anterior central and posterior) and compared them to follow-up brain imaging.

RESULTS

15 SAH patients (Fischer ≥ 3, World Federation of Neurological Surgeons scale ≥4, 9 DCI) were monitored during 6.4 [4-8] days (min = 2d, max = 13d). AT/D changes could follow three different patterns: (1) prolonged or (2) transient decrease and (3) no decrease or progressive increase. A regional 30% decrease outlasting 3.7 h reached 100% sensitivity and 88.9% specificity to detect DCI. Only 22.6% were in a zone of uncertain diagnosis (3.7-8.04 h). These prolonged decreases, with a loss of transient changes, started in cortical areas evolving toward DCI, and preceded intracranial changes when available.

CONCLUSION

Although this study has a small sample size, prolonged AT/D decrease seems to be a reliable biomarker of DCI.

SIGNIFICANCE

cEEG changes are likely to precede cerebral infarction and could be useful at the bedside to detect DCI before irreversible damage.

Electronic Health Data Predict Outcomes After Aneurysmal Subarachnoid Hemorrhage

BACKGROUD

Using electronic health data, we sought to identify clinical and physiological parameters that in combination predict neurologic outcomes after aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We conducted a single-center retrospective cohort study of patients admitted with aSAH between 2011 and 2016. A set of 473 predictor variables was evaluated. Our outcome measure was discharge Glasgow Outcome Scale (GOS). For laboratory and physiological data, we computed the minimum, maximum, median, and variance for the first three admission days. We created a penalized logistic regression model to determine predictors of outcome and a multivariate multilevel prediction model to predict poor (GOS 1-2), intermediate (GOS 3), or good (GOS 4-5) outcomes.

RESULTS

One hundred and fifty-three patients met inclusion criteria; most were discharged with a GOS of 3. Multivariate analysis predictors of mortality (AUC 0.9198) included APACHE II score, Glasgow Come Scale (GCS), white blood cell (WBC) count, mean arterial pressure, variance of serum glucose, intracranial pressure (ICP), and serum sodium. Predictors of death/dependence versus independence (GOS 4-5)(AUC 0.9456) were levetiracetam, mechanical ventilation, WBC count, heart rate, ICP variance, GCS, APACHE II, and epileptiform discharges. The multiclass prediction model selected GCS, admission APACHE II, periodic discharges, lacosamide, and rebleeding as significant predictors; model performance exceeded 80% accuracy in predicting poor or good outcome and exceeded 70% accuracy for predicting intermediate outcome.

CONCLUSIONS

Variance in early physiologic data can impact patient outcomes and may serve as targets for early goal-directed therapy. Electronically retrievable features such as ICP, glucose levels, and electroencephalography patterns should be considered in disease severity and risk stratification scores.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

Mortality after Spontaneous Subarachnoid Hemorrhage: Causality and Validation of a Prediction Model

OBJECTIVE

To evaluate primary causes of death after spontaneous subarachnoid hemorrhage (SAH) and externally validate the HAIR score, a prognostication tool, in a single academic institution.

METHODS

We reviewed all patients with SAH admitted to our neuro-intensive care unit between 2010 and 2016. Univariate and multivariate logistic regressions were performed to identify predictors of in-hospital mortality. The HAIR score predictors were Hunt and Hess grade at treatment decision, age, intraventricular hemorrhage, and rebleeding within 24 hours. Validation of the HAIR score was characterized with the receiver operating curve, the area under the curve, and a calibration plot.

RESULTS

Among 434 patients with SAH, in-hospital mortality was 14.1%. Of the 61 mortalities, 54 (88.5%) had a neurologic cause of death or withdrawal of care and 7 (11.5%) had cardiac death. Median time from SAH to death was 6 days. The main causes of death were effect of the initial hemorrhage (26.2%), rebleeding (23%) and refractory cerebral edema (19.7%). Factors significantly associated with in-hospital mortality in the multivariate analysis were age, Hunt and Hess grade, and intracerebral hemorrhage. Maximum lumen size was also a significant risk factor after aneurysmal SAH. The HAIR score had a satisfactory discriminative ability, with an area under the curve of 0.89.

CONCLUSIONS

The in-hospital mortality is lower than in previous reports, attesting to the continuing improvement of our institutional SAH care. The major causes are the same as in previous reports. Despite a different therapeutic protocol, the HAIR score showed good discrimination and could be a useful tool for predicting mortality.

Hunt-Hess 5 subarachnoid haemorrhage presenting with cardiac arrest is associated with larger volume bleeds

AIMS

The mechanism, effects, and outcomes of cardiac arrest (CA) caused by subarachnoid haemorrhage (SAH) remain unclear. We compared SAH patients presenting with CA to other high-grade SAH patients presenting without CA in order to better understand (1) the cause of CA, (2) cerebral pathophysiology following CA, and (3) outcomes of CA in patients with SAH.

METHODS

We performed a retrospective analysis of a prospectively collected observational cohort. 31 Hunt-Hess 5 patients that presented with CA were compared to 146 Hunt-Hess 5 patients that presented without CA. Clinical and imaging findings were predefined and adjudicated. Cerebral physiology measures were available for a subset of patients, matched 1:1 by age.

RESULTS

Twenty-two (71%) CA patients had pulseless electrical activity/asystole compared to 2 (6%) with a shockable rhythm. The CA patients were younger (OR 0.96, 95% CI 0.93-0.99, p=0.009), had more SAH on CT (OR 1.07, 95% CI 1.01-1.13, p=0.02), and had higher in-hospital mortality (87% vs. 58%, OR 6.2 (2.1-26.6), p=0.004). There were no differences in aneurysm location, cerebral herniation, or ictal seizures. Despite similar cerebral perfusion pressure, CA patients had pathologically lower brain tissue oxygenation, lower glucose, and higher lactate to pyruvate ratios.

CONCLUSIONS

CA in SAH is associated with larger volume bleeds. Despite normal cerebral perfusion pressures, CA patients show compromised cerebral physiology.

Prognosticating Functional Outcome After Intracerebral Hemorrhage: The ICHOP Score

BACKGROUND

The morbidity, mortality, and monetary cost associated with intracerebral hemorrhage (ICH) is devastatingly high. Several scoring systems have been proposed to prognosticate outcomes after ICH, although the original ICH Score is still the most widely used. However, recent research suggests that systemic physiologic factors, such as those included in the Acute Physiology and Chronic Health Evaluation II score, may also influence outcome. In addition, no scoring systems to date have included premorbid functional status. Therefore, we propose a scoring system that incorporates these factors to prognosticate 3-month and 12-month functional outcomes.

METHODS

We used the Random Forest machine-learning technique to identify factors from a dataset of more than 200 data points per patient that were most strongly affiliated with functional outcome. We then used linear regression to create an initial model based on these factors and modified weightings to improve accuracy. Our scoring system was compared with the ICH Score for prognosticating functional outcomes.

RESULTS

Two separate scoring systems (Intracerebral Hemorrhage Outcomes Project 3 [ICHOP₃] and ICHOP₁₂) were developed for 3-month and 12-month functional outcomes using Glasgow Coma Scale, National Institutes of Health Stroke Scale, Acute Physiology and Chronic Health Evaluation II, premorbid modified Rankin Scale (mRS), and hematoma volume (3-month only). Patient outcomes were dichotomized into good (mRS score, 0-3) and poor (mRS score, 4-6) categories based on functional status. Areas under the curve in the derivation cohort for predicting mRS score were 0.89 (3-month) and 0.87 (12-month); both were significantly more discriminatory than the original ICH Score.

CONCLUSIONS

The ICHOP scores may provide more comprehensive evaluation of a patient's long-term functional prognosis by taking into account systemic physiologic factors as well as premorbid functional status.

The Role of Platelet-Derived Growth Factor Receptor in Early Brain Injury Following Subarachnoid Hemorrhage

OBJECTIVE

This study aims to observe encephaledema and cell apoptosis in rats following subarachnoid hemorrhage (SAH) and to explore the mechanism of platelet-derived growth factor receptor (PDGFR) in the development of early brain injury (EBI).

METHODS

Adult and male Sprague-Dawley rats were randomly divided into 4 groups: sham operation, SAH, SAH + imatinib, and SAH + platelet-derived growth factor-BB (PDGF-BB). SAH model was established using intravascular silk puncture of the internal carotid artery crotch. The SAH + imatinib group was treated with intraperitoneal injection of imatinib 1 hour before establishing the model. The SAH + PDGF-BB group was administered with intracerebroventricular injection of PDGF-BB 1 hour before establishing the model. The mortality, encephaledema, and nerve functional scoring were observed after 24 hours in all groups. The expression of caspase-3 in hippocampus was tested by reverse transcription polymerase chain reaction and Western blotting.

RESULTS

Mortality and encephaledema were the highest in the SAH + PDGF-BB group, which were alleviated when the rats were injected with imatinib (P < .01).

CONCLUSION

PDGFR may participate in the pathogenesis of EBI following SAH. The antagonist of PDGFR, imatinib, can reduce brain damage to some degree.

Prognostication of long-term outcomes after subarachnoid hemorrhage: The FRESH score

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.

Who is Likely to Present in Poor Neurologic Condition After Aneurysmal Subarachnoid Hemorrhage? Risk Factors and Implications for Treatment

OBJECTIVE

Neurologic condition at presentation is the most important predictor of morbidity and mortality from aneurysmal subarachnoid hemorrhage (aSAH). To guide management, it is important to identify patients who are at risk of presenting in poor neurologic condition after aSAH.

METHODS

We retrospectively reviewed medical records and imaging studies for 387 consecutive cases of aSAH that were managed at a major academic neurovascular center in the United States from January 2008 to December 2013. Clinically accessible patient and aneurysm characteristics were evaluated by univariable analysis and multivariable logistic regression to identify predictors of poor neurologic status at presentation.

RESULTS

For all aneurysms, multivariable logistic regression identified age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.04; P = 0.0129), aneurysm size (≥7 and <10 mm: OR, 1.78; 95% CI, 1.02-3.11; P = 0.0429; ≥10 mm: OR, 3.22; 95% CI, 1.82-5.70; P < 0.0001), and vertebrobasilar junction location (OR, 10.1; 95% CI, 1.93-52.5; P = 0.0060) as independent predictors of poor neurologic condition at presentation. For internal carotid artery (ICA) aneurysms, female gender (OR, 9.21; 95% CI, 1.54-55.1; P = 0.0151), hypertension (OR, 8.67; 95% CI, 1.80-41.7; P = 0.007), and size ≥7 mm (OR, 3.67; 95% CI, 0.852-15.8; P = 0.0807) were predictive of poor neurologic condition at presentation, with a C statistic of 0.842. No association was found between poor neurologic grade at presentation and smoking status or warfarin therapy.

CONCLUSIONS

Independent predictors of poor neurologic grade were identified for all, ICA, anterior cerebral artery/anterior communicating artery, middle cerebral artery, and posterior circulation aneurysms. A risk prediction chart was constructed using clinically accessible patient and aneurysm characteristics for poor presenting neurologic condition after ICA aneurysm rupture. These factors should be considered when counseling patients with unruptured intracranial aneurysms.