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Gams Massi D, Pazeu MD, Motah M, Magnerou AM, Kenmegne C, Mbahé S, Mapoure NY. Spontaneous subarachnoid hemorrhage in a referral health Centre in Central Africa. eNeurologicalSci 2024; 36:100518. [PMID: 39139148 PMCID: PMC11321439 DOI: 10.1016/j.ensci.2024.100518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 07/03/2024] [Accepted: 07/19/2024] [Indexed: 08/15/2024] Open
Abstract
Background Spontaneous subarachnoid hemorrhage (sSAH) is a medicosurgical emergency with high morbidity and mortality. The aimed of this study was to describe the clinical features and outcome of sSAH in Cameroon. Methods We reviewed medical records of patients aged ≥15 years old, admitted for sSAH from Januray 2011 to December 2020 in the Douala General Hospital. The diagnosis of sSAH was confirmed by neuroimaging (CT scan or MRI). Clinical and radiological severities were assessed by the WFNS score and the modified Fisher score respectively. Factors associated to in-hospital mortality was identified using cross-table (RR and 95%CI). Results Among the 111 cases of sSAH reviewed in emergencies records, we included 70 patients. The mean age was of 55.6 ± 13.6 years. Female were predominant (57.1%). Altered consciousness was the main clinical feature (55.7%). The WFNS score was grade 4-5 in 54.3% of patients. And 75.7% of cases presented a modified Fisher score of 3-4. Ruptured of intracranial aneurysm was the most common etiology (46.2%). Endovascular treatment and/or surgical treatment were not avaible. Hospital-based mortality was 40% and factor associated with death were Altered consciousness (RR: 4.3, 95%CI:1.52-12.33, p = 0.004), coma (RR: 23.9, 95%CI:2.85-200.62, p = 0.004), WFNS grade 5 (RR: 18.2, 95%CI:3.7-92.3, p < 0.001), and hospital length ≤ 7 days (RR: 13.5, 95%CI:4.28-42.56, p < 0.001). Conclusion Mortality and disability of sSAH are still high in our setting. Further studies with prospective follow up of patients are needed to determine the long-term outcome of these patients.
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Affiliation(s)
- Daniel Gams Massi
- Neurology unit, Douala General Hospital, Douala, Cameroon
- Faculty of Health Sciences, University of Buea
| | - Mikael Doufiene Pazeu
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Mathieu Motah
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Annick Melanie Magnerou
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
- Neurology department, Douala Laquintinie Hospital, Douala, Douala, Cameroon
| | | | - Salomon Mbahé
- Neurology unit, Douala General Hospital, Douala, Cameroon
| | - Njankouo Yacouba Mapoure
- Neurology unit, Douala General Hospital, Douala, Cameroon
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
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Denneman N, Post R, Coert BA, van den Berg R, Verbaan D, Vandertop WP. Resilience After High-Grade Subarachnoid Hemorrhage: A Prospective Cohort Study on Quality of Life. Neurosurgery 2024:00006123-990000000-01233. [PMID: 38912823 DOI: 10.1227/neu.0000000000003047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 04/19/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Treatment of patients who present with poor clinical condition is often postponed until neurological improvement is observed. Despite previous studies, it is still unclear how survivors perceive their quality of life (QoL). This study aimed to evaluate self-perceived QoL in patients with aneurysmal subarachnoid hemorrhage who present with poor clinical condition, as defined by World Federation of Neurosurgical Societies (WFNS) grades 4 to 5, compared with those who present in more favorable clinical condition (WFNS 1-3). METHODS Between 2011 and 2021, 1160 patients with aneurysmal subarachnoid hemorrhage were admitted to the Amsterdam UMC. Among the 845 patients who survived, 537 participated in the QoL questionnaires. Patient characteristics, complications, EQ-5D questionnaires, modified Rankin Scale, and Hospital Anxiety and Depression Scale were analyzed using the nonparametric Mann-Whitney U test for continuous variables or the Pearson χ2 test for categorical variables. RESULTS Of the 537 responders, 452 (84%) presented with low grade (WFNS 1-3) and 85 (16%) presented with high grade (WFNS 4-5). The high-grade group reported a self-perceived QoL score of 70 (of 100), while the low-grade group reported a score of 75 (P = .12). The mean EQ-5D index value was 0.74 for the high-grade group and 0.81 for the low-grade group (P < .01). In the high-grade group, 61 patients (72%) had a favorable outcome (modified Rankin Scale 0-3) compared with 419 (94%) in the low-grade group (P < .001). CONCLUSION High-grade WFNS patients rated their QoL as satisfactory, with only a marginal 5-point difference on a 100-point scale compared with low-grade WFNS patients. In addition, almost three-quarters of high-grade WFNS survivors achieved a favorable outcome. Given that a subset of patients, despite presenting with a poor clinical condition, still achieve a favorable outcome, these findings reinforce our perspective advocating for early and comprehensive treatment.
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Affiliation(s)
- Nadine Denneman
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam UMC, Amsterdam, The Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam UMC, Amsterdam, The Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam UMC, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam UMC, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam UMC, Amsterdam, The Netherlands
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Bhargava Odak D, Saffwan M, Hanif S, Visca A, Eldridge P. Management of poor grade sub-arachnoid haemorrhage - clinical judgement v/s a formal model. Br J Neurosurg 2024; 38:433-438. [PMID: 33650920 DOI: 10.1080/02688697.2021.1885621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 08/13/2020] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The poor grade subarachnoid haemorrhage patients represent a unique cohort with lack of clear treatment protocol. Most neurosurgical units in the UK will manage them at local hospital until they make a significant recovery, this period can put them at higher risk of rebleed while with aggressive treatment a significant subset can achieve a favourable outcome. Identification of this subset is difficult and decision to treat them is associated with significant commitment of neurosurgical and ITU resources. Recent paper by Szklener has come up with a scale for prognostication in this subgroup of patients. We wanted to check the validity of this scale in our patient population and see if this scale can be used to guide early patient transfer and aggressive management at the Neurosurgical unit. METHODS We retrospectively reviewed our referral database for all poor grade subarachnoid patients referred over 2 years. Demographic information, Fisher and WFNS scores, admitting leucocyte count and outcome information as per MRS were obtained. These were scored as per the scale suggested by Szklener. RESULTS A total of 115 poor grade subarachnoid patients were referred over the study time frame. 47 of them were accepted for admission . 18/47 patients achieved a favourable outcome (GOS4-5). Only 1 patient managed in peripheral hospital had a good outcome. There was a significant association between Szklener's score and achieving a favourable outcome p = 0.002. CONCLUSION A selective admission policy could work specially with current economic climate, achieving outcomes comparable to admit-all. However, to optimise outcomes for all patients an aggressive standardised management at peripheral hospitals and a uniform admission policy assisted by Szklener score may be adopted. Szklener's model predicts the outcome better than WFNS and age but more validation is needed.
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Affiliation(s)
- Deepti Bhargava Odak
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Mohamed Saffwan
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Shahid Hanif
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Anna Visca
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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Shu L, Yan H, Wu Y, Yan T, Yang L, Zhang S, Chen Z, Liao Q, Yang L, Xiao B, Ye M, Lv S, Wu M, Zhu X, Hu P. Explainable machine learning in outcome prediction of high-grade aneurysmal subarachnoid hemorrhage. Aging (Albany NY) 2024; 16:4654-4669. [PMID: 38431285 PMCID: PMC10968679 DOI: 10.18632/aging.205621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/29/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Accurate prognostic prediction in patients with high-grade aneruysmal subarachnoid hemorrhage (aSAH) is essential for personalized treatment. In this study, we developed an interpretable prognostic machine learning model for high-grade aSAH patients using SHapley Additive exPlanations (SHAP). METHODS A prospective registry cohort of high-grade aSAH patients was collected in one single-center hospital. The endpoint in our study is a 12-month follow-up outcome. The dataset was divided into training and validation sets in a 7:3 ratio. Machine learning algorithms, including Logistic regression model (LR), support vector machine (SVM), random forest (RF), and extreme gradient boosting (XGBoost), were employed to develop a prognostic prediction model for high-grade aSAH. The optimal model was selected for SHAP analysis. RESULTS Among the 421 patients, 204 (48.5%) exhibited poor prognosis. The RF model demonstrated superior performance compared to LR (AUC = 0.850, 95% CI: 0.783-0.918), SVM (AUC = 0.862, 95% CI: 0.799-0.926), and XGBoost (AUC = 0.850, 95% CI: 0.783-0.917) with an AUC of 0.867 (95% CI: 0.806-0 .929). Primary prognostic features identified through SHAP analysis included higher World Federation of Neurosurgical Societies (WFNS) grade, higher modified Fisher score (mFS) and advanced age, were found to be associated with 12-month unfavorable outcome, while the treatment of coiling embolization for aSAH drove the prediction towards favorable prognosis. Additionally, the SHAP force plot visualized individual prognosis predictions. CONCLUSIONS This study demonstrated the potential of machine learning techniques in prognostic prediction for high-grade aSAH patients. The features identified through SHAP analysis enhance model interpretability and provide guidance for clinical decision-making.
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Affiliation(s)
- Lei Shu
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Hua Yan
- Department of Emergency, Affiliated Hospital of Panzhihua University, Panzhihua 617000, Sichuan, China
| | - Yanze Wu
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Tengfeng Yan
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Li Yang
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Si Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Zhihao Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Qiuye Liao
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Lu Yang
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Bing Xiao
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Minhua Ye
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Shigang Lv
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Miaojing Wu
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Xingen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Ping Hu
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang 330006, Jiangxi, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang 330006, Jiangxi, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang 330006, Jiangxi, China
- Institute of Neuroscience, Nanchang University, Nanchang 330006, Jiangxi, China
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Choi YH, Ha EJ, Shim Y, Kim J, Choo YH, Kim HS, Lee SH, Kim KM, Cho WS, Kang HS, Kim JE. Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis. Neurocrit Care 2024; 40:177-186. [PMID: 37610642 DOI: 10.1007/s12028-023-01818-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/20/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH. METHODS This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used. RESULTS A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome. CONCLUSIONS The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.
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Affiliation(s)
- Young Hoon Choi
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea.
| | - Youngbo Shim
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jungook Kim
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary's Hospital and College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital and College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Sung Ho Lee
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kang Min Kim
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeoug Eun Kim
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
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Kobata H, Ikawa F, Sato A, Kato Y, Sano H. Significance of Pupillary Findings in Decision Making and Outcomes of World Federation of Neurological Societies Grade V Subarachnoid Hemorrhage. Neurosurgery 2023; 93:309-319. [PMID: 36825904 DOI: 10.1227/neu.0000000000002410] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/15/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND There is considerable debate regarding the definition of grade V subarachnoid hemorrhage (SAH). Recently, the Glasgow Coma Scale-Pupil (GCS-P) score was advocated for assessing traumatic brain injury. OBJECTIVE To study the significance of pupillary findings and GCS-P in the management and outcomes of the World Federation of Neurological Societies (WFNS) grade V SAH. METHODS We analyzed data obtained from a Japanese nationwide prospective registration study on the modified WFNS SAH grading system. Bilateral pupillary dilatation without reactivity was defined as pupil score 2, unilateral pupil dilation without reactivity as score 1, and no pupil dilatation with reactivity as score 0. The GCS-P score was calculated by subtracting the pupil score from the total GCS score. The characteristics and pupillary findings were examined in patients with each GCS score in WFNS grade V. RESULTS Among 1638 patients, 472 (men/women = 161/311, age 67.0 ± 14.0 years) had a GCS score of ≤6 after initial resuscitation on arrival. Overall, lower GCS scores were associated with poorer neurological outcomes and higher mortality. Aneurysms were treated in 20.5%, 53.9%, and 67.5% of patients with pupil scores of 2, 1, and 0, respectively. Favorable outcomes (modified Rankin Scale 0-2) at 3 months occurred in 4.5%, 10.8%, and 21.4% in patients with pupil scores 2, 1, and 0, respectively ( P < .0001), and in 0%, 0%, 13.6%, 28.6%, 16.7%, and 18.8% of patients with GCS-P scores 1 to 6 ( P < .0001), respectively. CONCLUSION Our study confirmed the significance of pupillary findings in decision making and outcomes of WFNS grade V SAH.
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Affiliation(s)
- Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Akira Sato
- Gotanda Rehabilitation Hospital, Tokyo, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Nagoya, Aichi, Japan
| | - Hirotoshi Sano
- Department of Neurosurgery, Shinkawabashi Hospital, Kawasaki, Japan
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Mittal AM, Pease M, McCarthy D, Legarreta A, Belkhir R, Crago EA, Lang MJ, Gross BA. Hunt-Hess Score at 48 Hours Improves Prognostication in Grade 5 Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 171:e874-e878. [PMID: 36627019 DOI: 10.1016/j.wneu.2023.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients with Hunt-Hess (HH)5 aneurysmal subarachnoid hemorrhage (SAH) have high mortality rates. Despite an initial moribund exam, a subset of patients progress to favorable outcomes. OBJECTIVE To evaluate the utility of delayed HH grading to improve prognostication. METHODS We retrospectively reviewed patients undergoing treatment of ruptured aneurysms at two level 1 stroke centers from January 2012 through December 2020. We collected relevant clinical information and developed a multivariate cox regression model to identify independent predictors of mortality. To evaluate the utility of delayed examinations in predicting outcomes, we re-assessed the HH grade at 48 hours post admission and constructed a logistic regression model with potential confounders to predict mortality. RESULTS From 2012 to 2020, 621 patients underwent treatment for aneurysmal SAH. We identified 63 HH5 patients (10%) with a mean age of 58 years. Among these patients, the median length of stay was 14 days, with 3 patients passing away within 48 hours. The overall mortality rate was 63% at 24 months. To predict mortality, our cox regression model found only age to be significant (P = 0.002). Delayed HH grading improved prognostication at 48 hours and remained significant on multivariate analysis as a predictor of mortality (P = 0.0001). We observed a significant difference in mortality between patients HH5 and patients HH4 or lower at 48 hours (P = 0.0003). CONCLUSIONS Delayed reassessment of HH grade 48 hours postadmission is a predictor of mortality, suggesting reassessment at 48 hours in high grade SAH leads to better prognostication.
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Affiliation(s)
- Aditya M Mittal
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Matthew Pease
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David McCarthy
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Legarreta
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Raouf Belkhir
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Elizabeth A Crago
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Yang C, Zhang Z, Liao R, Li Y. Relationship between preoperative external ventricular drainage and preoperative rebleeding in aneurysmal subarachnoid hemorrhage: A meta-analysis. Clin Neurol Neurosurg 2023; 224:107563. [PMID: 36580739 DOI: 10.1016/j.clineuro.2022.107563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/09/2022] [Accepted: 12/16/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To analyze published evidence on the relationship between preoperative external ventricular drainage (preop-EVD) and preoperative rebleeding (preop-rebleeding) in aneurysmal subarachnoid hemorrhage (aSAH). METHOD A comprehensive search of three databases (PubMed, Ovid EMBASE, and The Cochrane Library) was conducted from their commencement to March 31, 2022. We collected studies reporting preop-EVD of rupture aneurysms while preop-rebleeding events were documented in these studies. We also extracted information on risk factors for preop-rebleeding from the studies and used Review Manager version 5.3 software to analyze. RESULTS A total of 3671 cases from 14 articles were enrolled in this meta-analysis. Preop-rebleeding rate was 11.04 % (106/960) and 9.22 % (250/2711) in preop-EVD group and control group, respectively. The study lacked power to conclude a clinically significant increase in preop-rebleeding risk (OR=1.60, 95 %CI:0.82-3.22). Fisher> 2 (OR=1.86), modified Fisher> 2 (OR=7.57), World Federation of Neurological Surgeons (WFNS)> 2 (OR=4.39) and aneurysm size > 1 cm (OR=3.01) were risk factors of preop-rebleeding. Patients with Hunt-Hess (HH)> 2 showed a higher preop-rebleeding trend compared to HH≤ 2, but the result did not reach a statistical difference (OR=6.79, P = 0.06). No difference in preop-rebleeding risk between anterior circulation aneurysms and posterior circulation aneurysms. Hydrocephalus had also been shown to be unrelated to higher preop-rebleeding rate. CONCLUSIONS Current evidence does not support that preop-EVD significantly increases the risk of rebleeding prior to aneurysm repair. Patients with poorer clinical status on admission and aneurysms size > 1 cm are at a higher risk of preop-rebleeding.
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Affiliation(s)
- Cheng Yang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Zhulin Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Rongjie Liao
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Yuhong Li
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
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Doherty RJ, Henry J, Brennan D, Javadpour M. Predictive factors for pre-intervention rebleeding in aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 46:24. [PMID: 36562905 DOI: 10.1007/s10143-022-01930-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/23/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
Rebleeding before intervention is a devastating complication of aneurysmal subarachnoid haemorrhage (aSAH). It often occurs early and is associated with poor outcomes. We present a systematic review and meta-analysis to identify potential predictors of rebleeding in aSAH. A database search identified studies detailing the occurrence of pre-intervention rebleeding in aSAH, and 809 studies were screened. The association between rebleeding and a variety of demographic, clinical, and radiological factors was examined using random effects meta-analyses. Fifty-six studies totalling 33,268 patients were included. Rebleeding occurred in 3,223/33,268 patients (11.1%, 95%CI 9.4-13), with risk decreasing by approximately 0.2% per year since 1981. Systolic blood pressure (SBP) during admission was higher in patients who rebled compared with those who did not (MD 7.4 mmHg, 95%CI 2.2 - 12.7), with increased risk in cohorts with SBP > 160 mmHg (RR 2.12, 95%CI 1.35-3.34), but not SBP > 140 mmHg. WFNS Grades IV-V (RR 2.05, 95%CI 1.13-3.74) and Hunt-Hess grades III-V (RR 2.12, 95%CI 1.38-3.28) were strongly associated with rebleeding. Fisher grades IV (RR 2.24, 95%CI 1.45-3.49) and III-IV (RR 2.05, 95%CI 1.17-3.6) were also associated with an increased risk. Awareness of potential risk factors for rebleeding is important when assessing patients with aSAH to ensure timely management in high-risk cases. Increased SBP during admission, especially > 160 mmHg, poorer clinical grades, and higher radiological grades are associated with an increased risk. These results may also aid in designing future studies assessing interventions aimed at reducing the risk of rebleeding.
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Affiliation(s)
- Ronan J Doherty
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland
| | - Jack Henry
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland
| | - David Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
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10
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Hori S, Kashiwazaki D, Akioka N, Okamoto S, Kubo M, Horie Y, Kuwayama N, Kuroda S. Predictive Factors of Functional Outcome in World Federation of Neurosurgical Societies Grade V Subarachnoid Hemorrhage. World Neurosurg 2022; 165:e216-e222. [PMID: 35688368 DOI: 10.1016/j.wneu.2022.05.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) frequently have poor outcomes. The current understanding of the predictors of functional outcome only in WFNS grade V SAH is limited. METHODS Patients with WFNS grade V SAH were retrospectively analyzed between April 2008 and August 2019. Surgical treatment is commonly delayed until clinical improvement is observed using a less aggressive approach. Clinical and radiologic data on admission were assessed, and disease-related characteristics were compared between patients with favorable outcomes (modified Rankin Scale score 0-3) and those with unfavorable outcomes (modified Rankin Scale score 4-6). RESULTS A total of 144 patients were included, and 22 patients (15.3%) achieved favorable outcomes, whereas 122 patients (84.7%) had unfavorable outcomes. Surgical aneurysm repair was performed in all patients with favorable outcomes and in 21.3% of those with unfavorable outcomes. Multivariate analysis showed that Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and hypertension were significantly associated with unfavorable outcomes (odds ratio [OR], 9.54, P = 0.03; OR, 5.37, P = 0.04; OR, 11.80, P = 0.009; OR, 0.14, P = 0.02 and OR, 6.53, P = 0.04, respectively). CONCLUSIONS The final outcome of patients with WFNS grade V SAH was still poor and highly predicted by Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and a history of hypertension. The efficacy of aggressive surgical treatment for these patients remains controversial, and the indications should be clearly defined in patients with desolate clinical status on admission.
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Affiliation(s)
- Satoshi Hori
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan; Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan.
| | - Daina Kashiwazaki
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
| | - Naoki Akioka
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
| | - Soshi Okamoto
- Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan
| | - Michiya Kubo
- Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan
| | - Yukio Horie
- Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan
| | - Naoya Kuwayama
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
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11
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de Winkel J, Cras TY, Dammers R, van Doormaal PJ, van der Jagt M, Dippel DWJ, Lingsma HF, Roozenbeek B. Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. BMC Neurol 2022; 22:239. [PMID: 35773634 PMCID: PMC9245240 DOI: 10.1186/s12883-022-02734-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment, although recent studies suggest that functional outcome following early aneurysm treatment has improved. We aimed to systematically review and meta-analyze early predictors of functional outcome in poor-grade aSAH patients. METHODS: We included studies investigating the association of early predictors and functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H-H) grade IV-V. Studies had to use multivariable regression analysis to estimate independent predictor effects of favorable functional outcome measured with the Glasgow Outcome Scale or modified Rankin Scale. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with random effects models. RESULTS: We included 27 studies with 3287 patients. The likelihood of favorable outcome increased with WFNS grade or H-H grade IV versus V (aOR 2.9, 95% CI 1.9-4.3), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0-5.3), and intact pupillary light reflex (aOR 2.9, 95% CI 1.6-5.1), and decreased with older age (aOR 0.7, 95% CI 0.5-1.0, per decade), increasing modified Fisher grade (aOR 0.4, 95% CI 0.3-0.5, per grade), and presence of intracerebral hematoma on admission imaging (aOR 0.4, 95% CI 0.2-0.8). CONCLUSIONS We present a summary of early predictors of functional outcome in poor-grade aSAH patients that can help to discriminate between patients with favorable and with unfavorable prognosis and may aid in selecting patients for early aneurysm treatment.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Tim Y Cras
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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12
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Raabe A, Beck J, Goldberg J, Z Graggen WJ, Branca M, Marbacher S, D'Alonzo D, Fandino J, Stienen MN, Neidert MC, Burkhardt JK, Regli L, Hlavica M, Seule M, Roethlisberger M, Guzman R, Zumofen DW, Maduri R, Daniel RT, El Rahal A, Corniola MV, Bijlenga P, Schaller K, Rölz R, Scheiwe C, Shah M, Heiland DH, Schnell O, Fung C. Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients With Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Stroke 2022; 53:2346-2351. [PMID: 35317612 DOI: 10.1161/strokeaha.121.036699] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Favorable outcomes are seen in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage. Therefore, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. We previously modified the WFNS scale by requiring positive signs of brain stem dysfunction to assign grade V. This study aimed to validate the new herniation WFNS grading system in an independent prospective cohort. METHODS We conducted an international prospective multicentre study in poor-grade aneurysmal subarachnoid hemorrhage patients comparing the WFNS classification with a modified version-the herniation WFNS scale (hWFNS). Here, only patients who showed positive signs of brain stem dysfunction (posturing, anisocoric, or bilateral dilated pupils) were assigned hWFNS grade V. Outcome was assessed by modified Rankin Scale score 6 months after hemorrhage. The primary end point was the difference in specificity of the WFNS and hWFNS grading with respect to poor outcomes (modified Rankin Scale score 4-6). RESULTS Of the 250 patients included, 237 reached the primary end point. Comparing the WFNS and hWFNS scale after neurological resuscitation, the specificity to predict poor outcome increased from 0.19 (WFNS) to 0.93 (hWFNS) (McNemar, P<0.001) whereas the sensitivity decreased from 0.88 to 0.37 (P<0.001), and the positive predictive value from 61.9 to 88.3 (weighted generalized score statistic, P<0.001). For mortality, the specificity increased from 0.19 to 0.93 (McNemar, P<0.001), and the positive predictive value from 52.5 to 86.7 (weighted generalized score statistic, P<0.001). CONCLUSIONS The identification of objective positive signs of brain stem dysfunction significantly improves the specificity and positive predictive value with respect to poor outcome in grade V patients. Therefore, a simple modification-presence of brain stem signs is required for grade V-should be added to the WFNS classification. REGISTRATION URL: https://clinicaltrials.gov; Unique identifier: NCT02304328.
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Affiliation(s)
- Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland (A.R., J.G., W.J.Z.)
| | - Jürgen Beck
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland (A.R., J.G., W.J.Z.)
| | - Werner J Z Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland (A.R., J.G., W.J.Z.)
| | | | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., D.D., J.F.)
| | - Donato D'Alonzo
- Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., D.D., J.F.)
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., D.D., J.F.)
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zürich Switzerland (M.N.S., M.C.N., L.R.)
| | - Marian C Neidert
- Department of Neurosurgery, University Hospital Zürich Switzerland (M.N.S., M.C.N., L.R.)
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University Hospital Zürich Switzerland, Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia (J.-K.B.)
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zürich Switzerland (M.N.S., M.C.N., L.R.)
| | - Martin Hlavica
- Department of Neurosurgery, Kantonsspital St. Gallen Switzerland (M.H., M.S.)
| | - Martin Seule
- Department of Neurosurgery, Kantonsspital St. Gallen Switzerland (M.H., M.S.)
| | | | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel Switzerland (M.R., R.G.)
| | - Daniel Walter Zumofen
- Department of Surgery, Neurology, and Radiology, Maimonides Medical Center, SUNY Downstate University, Brooklyn, NY (D.W.Z.)
| | - Rodolfo Maduri
- Avaton Surgical Group, Swiss Medical Network, Clinique de Genolier, Switzerland (R.M.)
| | - Roy Thomas Daniel
- Department of Neurosurgery, University Hospital Lausanne Switzerland (R.T.D.)
| | - Amir El Rahal
- Department of Neurosurgery, University Hospital Geneva, Switzerland (A.E.R., M.V.C., P.B., K.S.)
| | - Marco V Corniola
- Department of Neurosurgery, University Hospital Geneva, Switzerland (A.E.R., M.V.C., P.B., K.S.)
| | - Philippe Bijlenga
- Department of Neurosurgery, University Hospital Geneva, Switzerland (A.E.R., M.V.C., P.B., K.S.)
| | - Karl Schaller
- Department of Neurosurgery, University Hospital Geneva, Switzerland (A.E.R., M.V.C., P.B., K.S.)
| | - Roland Rölz
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Christian Scheiwe
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Mukesch Shah
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Oliver Schnell
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
| | - Christian Fung
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.)
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13
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Kano H, Takigami M, Matsui T, Bando K, Endo A, Nagama M. Successful Coil Embolization Using Percutaneous Cardiopulmonary Support in a Patient with Refractory Out-of-hospital Cardiac Arrest Caused by Aneurysmal Subarachnoid Hemorrhage. NMC Case Rep J 2022; 8:393-398. [PMID: 35079494 PMCID: PMC8769448 DOI: 10.2176/nmccrj.cr.2020-0379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/22/2020] [Indexed: 11/23/2022] Open
Abstract
In recent years, extracorporeal cardiopulmonary resuscitation (ECPR) has been reported to be an effective alternative to conventional CPR for treating patients with reversible causes of cardiac arrest. Nevertheless, the definite indication for ECPR and also surgical interventions during ECPR treatment have not been established, especially in patients with out-of-hospital cardiac arrest (OHCA) caused by subarachnoid hemorrhage (SAH). We treated a comatose 50-year-old woman with refractory cardiac arrest due to aneurysmal SAH-induced takotsubo cardiomyopathy (TCM). The initial cardiac rhythm was ventricular fibrillation. This is the first case report on coil embolization being successfully performed on a patient undergoing ECPR and therapeutic hypothermia (TH) while the patient was still in cardiac arrest, which resulted in complete social rehabilitation. Moreover, the success of this treatment suggests that ECPR and endovascular therapy should be considered for highly selected patients when cardiopulmonary and neurological functions are potentially reversible even in the setting of SAH.
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Affiliation(s)
- Hitoshi Kano
- Department of Neurosurgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Masayoshi Takigami
- Department of Neurosurgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Toshihisa Matsui
- Department of Emergency and Critical Care Center, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Keisuke Bando
- Department of Emergency and Critical Care Center, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Akio Endo
- Department of Emergency and Critical Care Center, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Masaki Nagama
- Department of Emergency and Critical Care Center, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
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14
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Chen Y, Cai Y, Chen H, Lin X, Zhou G, Yuan J, Fan Y. Influencing Factors for Complication with Aneurysm Rupture of the Fetal Posterior Communicating Artery After Clipping Through the Lateral Supraorbital Approach and Prognosis. Artery Res 2021. [DOI: 10.1007/s44200-021-00007-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Abstract
Background
To explore the influencing factors for complication with aneurysm rupture of the fetal posterior communicating artery after clipping through the lateral supraorbital (LSO) approach and prognosis.
Methods
A total of 119 patients with posterior communicating artery aneurysm (PCoAA) accompanied by fetal posterior cerebral artery (fPCA), who underwent clipping through the LSO approach from January 2014 to December 2019, were selected. They were aged 50–70 years old, (60.5 ± 13.7) on average. The treatment outcome, incidence of complications and follow-up results were analyzed. Based on the follow-up results, univariate comparative analysis was conducted for the clinical data of patients with good or poor prognosis. The statistically significant factors were incorporated into multivariate Cox regression analysis, and the nomogram prediction model for prognosis was established. The accuracy of the model was assessed using the Hosmer–Lemeshow goodness-of-fit test.
Results
Clipping through the LSO approach was successful in all cases. Perioperative complications occurred in 41 patients. According to the follow-up results, 89 patients had good prognosis, while 30 had poor prognosis. Age of > 65 years old, history of hypertension, high Hunt–Hess grade and high modified Fisher grade were independent risk factors for the poor prognosis of patients with PCoAA accompanied by fPCA after clipping through the LSO approach. The results obtained by the established model were consistent with the actual ones.
Conclusion
Age, history of hypertension, Hunt–Hess grade and modified Fisher grade are independent risk factors for the prognosis of patients with PCoAA accompanied by fPCA after clipping through the LSO approach.
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Abstract
PURPOSE OF REVIEW Subarachnoid hemorrhage (SAH) remains an important cause of mortality and long-term morbidity. This article uses a case-based approach to guide readers through the fundamental epidemiology and pathogenesis of SAH, the approach to diagnosis and management, the results of clinical trials and evidence to date, prognostic considerations, controversies, recent developments, and future directions in SAH. RECENT FINDINGS Historically, management of SAH focused on prevention and treatment of subsequent cerebral vasospasm, which was thought to be the primary cause of delayed cerebral ischemia. Clinical and translational studies over the past decade, including several therapeutic phase 3 randomized clinical trials, suggest that the pathophysiology of SAH-associated brain injury is multiphasic and multifactorial beyond large vessel cerebral vasospasm. The quest to reduce SAH-associated brain injury and improve outcomes is shifting away from large vessel cerebral vasospasm to a new paradigm targeting multiple brain injury mechanisms, including early brain injury, delayed cerebral ischemia, microcirculatory dysfunction, spreading cortical depolarization, inflammation, and the brain-body interaction in vascular brain injury with critical illness.Despite multiple negative randomized clinical trials in search of potential therapeutic agents ameliorating the downstream effects after SAH, the overall outcome of SAH has improved over recent decades, likely related to improvements in interventional options for ruptured cerebral aneurysms and in critical care management. Emerging clinical evidence also suggests potential harmful impact of historic empiric treatments for SAH-associated vasospasm, such as prophylactic induction of hypertension, hypervolemia, and hemodilution (triple H therapy).With decreasing mortality, long-term SAH survivorship and efforts to reduce chronic morbidity and to improve quality of life and patient-centered outcome are growing areas of unmet need. Despite existing guidelines, significant variabilities in local and regional practices and in scientific terminologies have historically limited advancement in SAH care and therapeutic development. Large global collaborative efforts developed harmonized SAH common data elements in 2019, and studies are under way to examine how existing variabilities in SAH care impact long-term SAH outcomes. SUMMARY Although the overall incidence and mortality of SAH is decreasing with advances in preventive and acute care, SAH remains a major cause of long-term morbidity in survivors. Significant variabilities in care settings and empiric treatment protocols and inconsistent scientific terminologies have limited advancement in patient care and therapeutic clinical studies. Large consensus efforts are under way to introduce clinical guidelines and common data elements to advance therapeutic approaches and improve patient outcome.
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Best Motor Response Predicts Favorable Outcome for "True" WFNS Grade V Patients with Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106075. [PMID: 34481320 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The universal application of ultra-early surgery for World Federation of Neurological Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (aSAH) patients may lead to the increased implementation of unnecessary treatment. Therefore, this study aimed to refine the patient selection process for timely definitive treatment. METHODS From January 2011 to March 2020, a total of 517 aSAH patients were treated at our institution. Among these, 177 aSAH patients with WFNS grade V on admission were identified from our database. Patients with improved grades in response to the initial supportive treatment, with clinical or radiological signs of herniation, and with irreversible signs of brain damage such as bilaterally dilated pupils and global ischemia on follow-up CT scan were excluded. The outcome of definitive treatment for 54 patients without herniation who remained with WFNS grade V after the initial supportive treatment were analyzed to seek any factor for a favorable outcome (modified Rankin scale 0-2). RESULTS Among 54 patients, 19 (35.2%) had a favorable outcome after a definitive treatment. Multivariate logistic regression analysis showed that the best motor response (BMR) 4 on Glasgow Coma Scale was significantly associated with favorable outcomes (odds ratio, 3.76; 95% confidence interval, 1.09-13.0, p = 0.03). The positive predictive value of BMR 4 was 48.3%. CONCLUSIONS Albeit being simple, BMR 4 may facilitate the prompt aggressive treatment for patients with WFNS grade V including those with "true" grade V who do not have any clinical and radiological signs of herniation.
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Wen LL, Zhou XM, Lv SY, Shao J, Wang HD, Zhang X. Outcomes of high-grade aneurysmal subarachnoid hemorrhage patients treated with coiling and ventricular intracranial pressure monitoring. World J Clin Cases 2021; 9:5054-5063. [PMID: 34307556 PMCID: PMC8283582 DOI: 10.12998/wjcc.v9.i19.5054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/08/2021] [Accepted: 05/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND High-grade aneurysmal subarachnoid hemorrhage is a devastating disease with a low favorable outcome. Elevated intracranial pressure is a substantial feature of high-grade aneurysmal subarachnoid hemorrhage that can result to secondary brain injury. Early control of intracranial pressure including decompressive craniectomy and external ventricular drainage had been reported to be associated with improved outcomes. But in recent years, little is known whether external ventricular drainage and intracranial pressure monitoring after coiling could improve outcomes in high-grade aneurysmal subarachnoid hemorrhage.
AIM To investigate the outcomes of high-grade aneurysmal subarachnoid hemorrhage patients with coiling and ventricular intracranial pressure monitoring.
METHODS A retrospective analysis of a consecutive series of high-grade patients treated between Jan 2016 and Jun 2017 was performed. In our center, followed by continuous intracranial pressure monitoring, the use of ventricular pressure probe for endovascular coiling and invasive intracranial pressure monitoring in the acute phase is considered to be the first choice for the treatment of high-grade patients. We retrospectively analyzed patient characteristics, radiological features, intracranial pressure monitoring parameters, complications, mortality and outcome.
RESULTS A total of 36 patients were included, and 32 (88.89%) survived. The overall mortality rate was 11.11%. No patient suffered from aneurysm re-rupture. The intracranial pressure in 33 patients (91.67%) was maintained within the normal range by ventricular drainage during the treatment. A favorable outcome was achieved in 18 patients (50%) with 6 mo follow-up. Delayed cerebral ischemia and Glasgow coma scale were considered as significant predictors of outcome (2.066 and -0.296, respectively, P < 0.05).
CONCLUSION Ventricular intracranial pressure monitoring may effectively maintain the intracranial pressure within the normal range. Despite the small number of cases in the current work, high-grade patients may benefit from a combination therapy of early coiling and subsequent ventricular intracranial pressure monitoring.
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Affiliation(s)
- Li-Li Wen
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, Jiangsu Province, China
| | - Xiao-Ming Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, Jiangsu Province, China
| | - Sheng-Yin Lv
- Department of Neurology, The Second Hospital of Nanjing, Nanjing 210003, Jiangsu Province, China
| | - Jiang Shao
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, Jiangsu Province, China
| | - Han-Dong Wang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, Jiangsu Province, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, Jiangsu Province, China
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18
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Mahta A, Murray K, Reznik ME, Thompson BB, Wendell LC, Furie KL. Early Neurological Changes and Interpretation of Clinical Grades in Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105939. [PMID: 34171650 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/29/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Hunt and Hess (HH) and World Federation of Neurological Surgeons (WFNS) grades are commonly used to report clinical severity of aneurysmal subarachnoid hemorrhage (aSAH). We sought to determine the impact of early neurological changes and the timing of clinical grade assignment on the prognostication accuracy. METHODS We retrospectively reviewed a cohort of consecutive patients with aSAH who were admitted to an academic center. Patients with confirmed aneurysmal cause were included. Relevant clinical data including daily clinical grades, imaging data and functional outcome were analyzed. Favorable outcome was defined as mRS 0 to 3. Early neurological improvement (ENI) and early neurological deterioration (END) were respectively defined as any improvement or deterioration of HH grades from hospital day 1 to the earliest time from hospital day 2 to 5. RESULTS Of 310 patients, 24% experienced early neurological changes from hospital day 1 to 3. For each point increase in HH grades from day 1 to day 3, the odds ratio for worse outcome was 2.57 (95% CI [1.74-3.79]) and for each point decrease in HH grades from day 1 to day 3, the odds ratio for worse outcome was 0.28 (95% CI [0.17-0.47]). Receiver Operating Characteristic curve analysis revealed that clinical grades on day 3 had higher accuracy in predicting worse outcome than clinical grades on day 1. CONCLUSION Early changes in neurological status can alter trajectory of hospital course and functional outcome. The prognostic accuracy of the clinical grades from hospital day 3 is significantly greater than those on admission.
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Affiliation(s)
- Ali Mahta
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Kayleigh Murray
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael E Reznik
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Bradford B Thompson
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Linda C Wendell
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
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19
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Gouvêa Bogossian E, Diaferia D, Minini A, Ndieugnou Djangang N, Menozzi M, Peluso L, Annoni F, Creteur J, Schuind S, Dewitte O, Taccone FS. Time course of outcome in poor grade subarachnoid hemorrhage patients: a longitudinal retrospective study. BMC Neurol 2021; 21:196. [PMID: 33985460 PMCID: PMC8117582 DOI: 10.1186/s12883-021-02229-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Background Neurological outcome and mortality of patients suffering from poor grade subarachnoid hemorrhage (SAH) may have changed over time. Several factors, including patients’ characteristics, the presence of hydrocephalus and intraparenchymal hematoma, might also contribute to this effect. The aim of this study was to assess the temporal changes in mortality and neurologic outcome in SAH patients and identify their predictors. Methods We performed a single center retrospective cohort study from 2004 to 2018. All non-traumatic SAH patients with poor grade on admission (WFNS score of 4 or 5) who remained at least 24 h in the hospital were included. Time course was analyzed into four groups according to the years of admission (2004–2007; 2008–2011; 2012–2015 and 2016–2018). Results A total of 353 patients were included in this study: 202 patients died (57 %) and 260 (74 %) had unfavorable neurological outcome (UO) at 3 months. Mortality tended to decrease in in 2008–2011 and 2016–2018 periods (HR 0.55 [0.34–0.89] and HR 0.33 [0.20–0.53], respectively, when compared to 2004–2007). The proportion of patients with UO remained high and did not vary significantly over time. Patients with WFNS 5 had higher mortality (68 % vs. 34 %, p = 0.001) and more frequent UO (83 % vs. 54 %, p = 0.001) than those with WFNS 4. In the multivariable analysis, WFNS 5 was independently associated with mortality (HR 2.12 [1.43–3.14]) and UO (OR 3.23 [1.67–6.25]). The presence of hydrocephalus was associated with a lower risk of mortality (HR 0.60 [0.43–0.84]). Conclusions Both hospital mortality and UO remained high in poor grade SAH patients. Patients with WFNS 5 on admission had worse prognosis than others; this should be taken into consideration for future clinical studies. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02229-1.
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Affiliation(s)
- Elisa Gouvêa Bogossian
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Daniela Diaferia
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Narcisse Ndieugnou Djangang
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Menozzi
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery Erasmus Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Olivier Dewitte
- Department of Neurosurgery Erasmus Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
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20
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Findings Predictive of Poor Outcome in Grade 5 Subarachnoid Hemorrhage: A Cohort Study. Can J Neurol Sci 2021; 48:807-816. [PMID: 33472716 DOI: 10.1017/cjn.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most patients with World Federation of Neurological Surgeons (WFNS) grade 5 subarachnoid hemorrhage (SAH) have poor outcomes. Accurate assessment of prognosis is important for treatment decisions and conversations with families regarding goals of care. Unjustified pessimism may lead to "self-fulfilling prophecy," where withdrawal of life-sustaining measures (WLSM) is invariably followed by death. METHODS We performed a cohort study involving consecutive patients with WFNS grade 5 SAH to identify variables with >= 90% and >= 95% positive predictive value (PPV) for poor outcome (1-year modified Rankin Score >= 4), as well as findings predictive of WLSM. RESULTS Of 140 patients, 38 (27%) had favorable outcomes. Predictors with >= 95% PPV for poor outcome included unconfounded 72-hour Glasgow Coma Scale motor score <= 4, absence of >= 1 pupillary light reflex (PLR) at 24 hours, and intraventricular hemorrhage (IVH) score of >= 20 (volume >= 54.6 ml). Intracerebral hemorrhage (ICH) volume >= 53 ml had PPV of 92%. Variables associated with WLSM decisions included a poor motor score (p < 0.0001) and radiographic evidence of infarction (p = 0.02). CONCLUSIONS We identified several early predictors with high PPV for poor outcome. Of these, lack of improvement in motor score during the initial 72 hours had the greatest potential for confounding from "self-fulfilling prophecy." Absence of PLR at 24 hours, IVH score >= 20, and ICH volume >= 53 ml predicted poor outcome without a statistically significant effect on WLSM decisions. More research is needed to validate prognostic variables in grade 5 SAH, especially among patients who do not undergo WLSM.
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21
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Chen C, Guo X, Chen Y, Zheng K, Zhou J, Wang H, Yang Y, Lin B. Predictors of Poor-Grade Aneurysmal Subarachnoid Hemorrhage Caused by Anterior Communicating Artery Aneurysm. World Neurosurg 2021; 148:e340-e345. [PMID: 33412327 DOI: 10.1016/j.wneu.2020.12.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/27/2020] [Accepted: 12/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) are considered to have a poor prognosis. However, the underlying reason for the association between the aneurysmal characteristics and poor-grade aSAH is still unclear. In the present study, we retrospectively evaluated the independent risk factors for patients with anterior communicating artery (ACoA) aneurysms with poor-grade aSAH. METHODS From January 2009 to January 2016, 477 consecutive patients with ruptured ACoA aneurysms were included in the present study. Poor-grade aSAH was defined as a World Federation of Neurosurgical Society grade of IV or V, and good-grade aSAH was defined as a grade of I-III. Univariate and multivariable regression analyses were used to investigate the differences in aneurysm morphology and clinical characteristics between the 2 groups. RESULTS On univariate analysis, older patients (P = 0.038), larger aneurysm size (P = 0.013), larger size ratio (P = 0.007), larger aspect ratio (P = 0.009), positive history of stroke (P = 0.001), and posterior projection aneurysms (P = 0.001) were associated with poor-grade aSAH. Multivariate analyses revealed that older patients (odds ratio [OR], 1.654; 95% confidence interval [CI], 1.004-2.728; P = 0.048), larger size ratio (OR, 1.280; 95% CI, 1.111-1.475; P = 0.001), positive history of stroke (OR, 6.051; 95% CI, 1.712-21.381; P = 0.005), and posterior projection aneurysms (OR, 2.718; 95% CI, 1.607-4.598; P < 0.001) were independently associated with poor-grade aSAH. CONCLUSIONS Poor-grade aSAH was independently associated with older patients, a larger size ratio, a positive history of stroke, and posterior projection aneurysms in patients with a ruptured ACoA aneurysm. These parameters could contribute to screening for patients with the potential for poor-grade aSAH.
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Affiliation(s)
- Chao Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xianzhong Guo
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yongchun Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Kuikui Zheng
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jiafeng Zhou
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Hao Wang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Boli Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
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22
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Nguyen TN, Jadhav AP, Dasenbrock HH, Nogueira RG, Abdalkader M, Ma A, Cervantes-Arslanian AM, Greer DM, Daneshmand A, Yavagal DR, Jovin TG, Zaidat OO, Chou SHY. Subarachnoid hemorrhage guidance in the era of the COVID-19 pandemic - An opinion to mitigate exposure and conserve personal protective equipment. J Stroke Cerebrovasc Dis 2020; 29:105010. [PMID: 32807425 PMCID: PMC7274572 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 02/07/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) patients require frequent neurological examinations, neuroradiographic diagnostic testing and lengthy intensive care unit stay. Previously established SAH treatment protocols are impractical to impossible to adhere to in the current COVID-19 crisis due to the need for infection containment and shortage of critical care resources, including personal protective equipment (PPE). Centers need to adopt modified protocols to optimize SAH care and outcomes during this crisis. In this opinion piece, we assembled a multidisciplinary, multicenter team to develop and propose a modified guidance algorithm that optimizes SAH care and workflow in the era of the COVID-19 pandemic. This guidance is to be adapted to the available resources of a local institution and does not replace clinical judgment when faced with an individual patient.
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Affiliation(s)
- Thanh N Nguyen
- Neurology, Neurosurgery, Radiology, Boston Medical Center/Boston University School of Medicine.
| | | | | | - Raul G Nogueira
- Neurology, Neurosurgery, Radiology, Grady Memorial Hospital/Emory University.
| | | | - Alice Ma
- Radiology, Boston Medical Center.
| | | | | | | | - Dileep R Yavagal
- Neurology, Neurosurgery, University of Miami Miller School of Medicine.
| | | | - Osama O Zaidat
- Neuroscience Institute, Bon Secours Mercy Health System/ St. Vincent Hospital.
| | - Sherry Hsiang-Yi Chou
- Neurology, Neurosurgery, University of Pittsburgh Medical Center; Neurology, Neurosurgery, Critical Care Medicine, University of Pittsburgh Medical Center.
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23
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Ariyada K, Ohida T, Shibahashi K, Hoda H, Hanakawa K, Murao M. Long-term Functional Outcomes for World Federation of Neurosurgical Societies Grade V Aneurysmal Subarachnoid Hemorrhage after Active Treatment. Neurol Med Chir (Tokyo) 2020; 60:390-396. [PMID: 32669527 PMCID: PMC7431870 DOI: 10.2176/nmc.oa.2020-0052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
This study investigated the long-term outcomes of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (SAH) who underwent early aneurysm repair. We evaluated consecutive patients with WFNS grade V aneurysmal SAH from April 2010 to March 2015 who underwent aneurysm repair within 72 h after onset. We assessed the functional outcomes at discharge and 3 years after onset using the modified Rankin Scale (mRS). The primary outcome was defined as a favorable functional outcome (mRS ≤2). We identified 145 patients with grade V SAH during the study period. Of these, 44 patients (19 males and 25 females; median age, 64 years; range, 24–79 years) met the inclusion criteria. For aneurysm repair, surgical clipping and coiling were performed in 40 (90.9%) and 4 (9.1%) patients, respectively. Although no patient had a favorable functional outcome at discharge, 11 (25.0%) patients had a favorable functional outcome at the end of follow-up. The number of patients with a favorable outcome significantly increased during the first year (P = 0.012) and during the follow-up period (P <0.001). Patients who underwent active rehabilitation had significant improvement. Our study showed that one-fourth of the patients who underwent early aneurysm repair with WFNS grade V SAH achieved a mRS score of ≤2 over a 3-year period. It might be important to consider age and rehabilitation for better clinical outcomes. Larger studies are required to adequately assess the long-term functional outcomes and other multi-faceted prognoses.
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Affiliation(s)
- Kenichi Ariyada
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Tomoya Ohida
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Keita Shibahashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Hidenori Hoda
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Kazuo Hanakawa
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Masahiko Murao
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
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24
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Ojha M, Finnis ME, Heckelmann M, Raith EP, Moodie S, Chapman MJ, Reddi B, Maiden MJ. Outcomes following grade V subarachnoid haemorrhage: A single-centre retrospective study. Anaesth Intensive Care 2020; 48:289-296. [PMID: 32659113 DOI: 10.1177/0310057x20927033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
SummaryGrade V subarachnoid haemorrhage is associated with high mortality and morbidity, yet there are few contemporary reports on the treatment provided and outcomes of these patients. In this single-centre retrospective cohort study, we primarily sought to determine the 12-month mortality of patients admitted to the Royal Adelaide Hospital intensive care unit between 2006 and 2016 with grade V subarachnoid haemorrhage. Secondary objectives were to describe treatments provided, patient destination following hospital discharge, organ donation and hospital financial costs. Over the 11-year study period, there were 139 patients admitted with grade V subarachnoid haemorrhage. The annual number of admissions did not change over time. The median age was 56 (interquartile range 48-70) years, 88 (63%) were female and 77 (55%) had a procedure to isolate an aneurysm. There were 77 (55%) patients who died in the intensive care unit, 87 (63%) died in hospital and 89 (64%) had died at 12 months. Of the 52 patients who survived to hospital discharge, 33 (63%) were transferred to a rehabilitation facility, 17 (33%) to another acute care hospital and two (4%) were discharged. Of the 87 patients who died in hospital, 45 (52%) donated organs. The total hospital cost of managing this cohort was A$8.3 million, with a median cost of A$41,824 (interquartile range A$9,933-A$97,332) per patient. Grade V subarachnoid haemorrhage has a high mortality rate, with one-third of patients alive after one year.
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Affiliation(s)
- Minny Ojha
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michael Heckelmann
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Eamon P Raith
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stewart Moodie
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Donate Life SA, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Benjamin Reddi
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Matthew J Maiden
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,Intensive Care Unit, Barwon Health, Geelong, Australia
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25
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Kaneko J, Tagami T, Unemoto K, Tanaka C, Kuwamoto K, Sato S, Tani S, Shibata A, Kudo S, Kitahashi A, Yokota H. Functional Outcome Following Ultra-Early Treatment for Ruptured Aneurysms in Patients with Poor-Grade Subarachnoid Hemorrhage. J NIPPON MED SCH 2019; 86:81-90. [PMID: 31130569 DOI: 10.1272/jnms.jnms.2019_86-203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Little is known regarding functional outcome following poor-grade (World Federation of Neurosurgical Societies grades IV and V) aneurysmal subarachnoid hemorrhage (aSAH), especially in individuals treated aggressively in the early phase after ictus. METHODS We provided patients with aSAH with ultra-early definitive treatment, coiling or clipping, within 6 hours from arrival as per protocol. We classified the patients into 3 groups according to their computed tomography findings: Group 1, intraventricular hemorrhage with obstructive hydrocephalus; Group 2, massive intracerebral hemorrhage with brain herniation; and Group 3, neither Group 1 nor Group 2. We retrospectively evaluated patients with poor-grade aSAH who were admitted to our department between January 2013 and December 2016. We evaluated functional outcome at 6 months, defining modified Rankin Scale (mRS) scores of 0-2 as good and those of 3-6 as poor outcomes. RESULTS A good functional outcome was observed in 39.4% (28/71) of all cases. All-cause mortality at 6 months was 15.5% (11/71). A good outcome in Group 3 was significantly higher than that in the other two groups (Group 1 and 2 vs. Group 3, 20.8% vs. 48.9%, p = 0.02), even after adjustment with a multiple logistic regression analysis (odds ratio 6.1, 95% confidence interval 1.1 to 34.8). CONCLUSIONS Approximately 40% of patients with poor-grade aSAH became functionally independent, and approximately half of the patients with poor-grade aSAH who had neither intraventricular hemorrhage with obstructive hydrocephalus nor with brain herniation had good functional outcomes. Although further trials are required to confirm our results, ultra-early surgery may be considered for patients with poor-grade aSAH.
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Affiliation(s)
- Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital.,Health Services and Systems Research, Duke-NUS Medical School.,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Kyoko Unemoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Chie Tanaka
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | | | - Shin Sato
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Shosei Tani
- Department of Neurosurgery, Tominaga Hospital
| | - Ami Shibata
- Department of Neurosurgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Saori Kudo
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Akiko Kitahashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School
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26
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Hoogmoed J, de Oliveira Manoel AL, Coert BA, Marotta TR, Macdonald RL, Vandertop WP, Verbaan D, Germans MR. Why Do Patients with Poor-Grade Subarachnoid Hemorrhage Die? World Neurosurg 2019; 131:e508-e513. [PMID: 31398522 DOI: 10.1016/j.wneu.2019.07.221] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Poor-grade subarachnoid hemorrhage (SAH) has been associated with a high case fatality, either in the acute phase or in the later stages. The exact causes of death in these patients are unknown. METHODS We performed a retrospective study of all consecutive patients with SAH with World Federation of Neurosurgical Societies grade IV or V on admission from 2009 to 2013 at 2 tertiary referral centers in Amsterdam, the Netherlands, and Toronto, Ontario, Canada, who had died during their hospital stay. RESULTS Of 357 patients, 152 (43%) had died. Of these 152 patients, 87 (24%) had not undergone aneurysm treatment. The median interval to death was 3 days (interquartile range, 1-12 days) after initial hemorrhage. The major cause of death in both centers was withdrawal of life support (107 patients [71%]; 74 of 94 [79%] in Amsterdam and 33 of 58 [58%] in Toronto; P < 0.01), followed by brain death in 23 (15%; 16 of 58 [28%] in Amsterdam vs. 7 of 94 [7%] in Toronto; P < 0.01). The remaining causes of death represented <15%. CONCLUSIONS The decision to withdraw life support was the major reason for death of patients with poor-grade SAH for an overwhelming majority of the patients. The exact reasons for withdrawal of life support, other than cultural and referral differences, were undetermined. Insight into the reasons of death should be prospectively studied to improve the care and clinical outcomes of patients with poor-grade SAH.
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Affiliation(s)
- Jantien Hoogmoed
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Airton L de Oliveira Manoel
- Neurology and Neurosurgery Department, Universidade Federal de São Paulo, São Paulo, Brazil; Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, University of Toronto, Toronto, Ontario, Canada; Division of Interventional Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada; Neuroscience Research Program, Keenan Research Centre, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Thomas R Marotta
- Division of Interventional Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada; Neuroscience Research Program, Keenan Research Centre, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - R Loch Macdonald
- Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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27
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Ota N, Noda K, Hatano Y, Hashimoto A, Miyazaki T, Kondo T, Kinoshita Y, Kamiyama H, Tokuda S, Kamada K, Tanikawa R. Preoperative Predictors and Prognosticators After Microsurgical Clipping of Poor-Grade Subarachnoid Hemorrhage: A Retrospective Study. World Neurosurg 2019; 125:e582-e592. [DOI: 10.1016/j.wneu.2019.01.135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 11/28/2022]
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28
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Zheng K, Zhong M, Zhao B, Chen SY, Tan XX, Li ZQ, Xiong Y, Duan CZ. Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Risk Factors Affecting Clinical Outcomes in Intracranial Aneurysm Patients in a Multi-Center Study. Front Neurol 2019; 10:123. [PMID: 30873104 PMCID: PMC6400833 DOI: 10.3389/fneur.2019.00123] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 01/30/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: Patients with poor-grade aneurysm subarachnoid hemorrhage (SAH) have commonly been considered to have a poor prognosis. The objective of this study was to investigate the independent risk factors affecting clinical outcomes in intracranial aneurysm patients with poor-grade aneurysm subarachnoid hemorrhage (aSAH) underwent different intervention therapies. Methods: A multicenter observational registry of 324 poor-grade aSAH patients treated at tertiary referral centers from October 2010 to March 2012 were enrolled in this study. The clinical data including patient characteristics on admission and during treatment course, treatment modality, aneurysm size and location, radiologic features, signs of cerebral herniation (dilated pupils), and functional neurologic outcome were collected. Clinical outcomes were assessed via a modified Rankin Scale at 12 months. Multivariate logistic regression models were used to develop prognostic models. The area under the receiver operator characteristic curves (AUC) and Hosmer-Lemeshow tests were used to assess discrimination and calibration. WAP score was developed to predict risk of poor outcome. Results: Older age, female gender, ventilated breathing status, non-reactive pupil response, pupil dilation, lower GCS score, a WFNS grade of V, intraventricular hemorrhage, a higher Fisher grade, a higher modified Fisher grade, and conservative treatment were calculated to be associated with a relatively poor outcome. Multivariate analyses revealed that older age, lower Glasgow coma scale score (GCS), the absence of pupillary reactivity, higher modified Fisher grade, and conservative treatment were independent predictors of poor outcome, showed good discrimination and calibration. Patients with WFNS grade V, older age and non-reactive pupillary reactivity were predicted to have a poor outcome by WAP risk score. Conclusions: A simple WAP risk score had good discrimination and calibration in the prediction of outcome. The risk score can be easily measured and may complement treatment decision-making.
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Affiliation(s)
- Kuang Zheng
- Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, The National Key Clinic Specialty, The Neurosurgery Institute of Guangdong Province, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ming Zhong
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bing Zhao
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Si-Yan Chen
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xian-Xi Tan
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ze-Qun Li
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Xiong
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chuan-Zhi Duan
- Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, The National Key Clinic Specialty, The Neurosurgery Institute of Guangdong Province, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Ironside N, Buell TJ, Chen CJ, Kumar JS, Paisan GM, Sokolowski JD, Liu KC, Ding D. High-Grade Aneurysmal Subarachnoid Hemorrhage: Predictors of Functional Outcome. World Neurosurg 2019; 125:e723-e728. [PMID: 30735864 DOI: 10.1016/j.wneu.2019.01.162] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/16/2019] [Accepted: 01/19/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Because the prognosis of high-grade aneurysmal subarachnoid hemorrhage (aSAH), classified as World Federation of Neurosurgical Societies (WFNS) grade IV-V, is generally poor, the functional outcomes of survivors have not been thoroughly explored. The aim of this retrospective cohort study is to determine predictors of functional independence in patients who survive a high-grade aSAH. METHODS We retrospectively evaluated consecutive patients with aSAH admitted to a single institution from January 2000 to April 2015. Adult (age ≥18 years) patients with WFNS grade IV-V aSAH were included for analysis. Patients without sufficient baseline data, those who died before discharge, and those without follow-up data were excluded. Univariable and multivariable logistic regression analyses were used to identify factors associated with functional independence, defined as a modified Rankin Scale score of 0-2, at last follow-up. RESULTS Of the 260 patients with a WFNS grade IV-V aSAH during the study period, 139 met the inclusion criteria. After a mean follow-up of 6.3 months, functional independence was achieved in 73% of high-grade aSAH survivors (101/139 patients) and in 39% of all high-grade aSAH cases (101/260 patients). Only a lack of cerebrospinal fluid shunt placement was found to be an independent predictor of functional independence in the multivariable analysis (odds ratio 0.28 [0.109-0.722]; P = 0.008). CONCLUSIONS Because functional independence can be achieved in the majority of high-grade aSAH survivors, aggressive initial management of high-grade aSAH is warranted. Strategies that reduce the need for permanent cerebrospinal fluid diversion may improve functional outcomes in survivors of high-grade aSAH.
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Affiliation(s)
- Natasha Ironside
- Department of Neurosurgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jeyan S Kumar
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Gabriella M Paisan
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jennifer D Sokolowski
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Kenneth C Liu
- Department of Neurosurgery, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.
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30
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Zheng J, Xu R, Guo Z, Sun X. Alanine Aminotransferase Predicts Outcomes in Elderly Patients with Aneurysmal Subarachnoid Hemorrhage. Curr Neurovasc Res 2019; 16:89-95. [PMID: 30706813 DOI: 10.2174/1567202616666190130094631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/12/2019] [Accepted: 01/18/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE With the aging of the world population, the number of elderly patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) is gradually growing. We aim to investigate the potential association between plasma ALT level and clinical complications of elderly aSAH patients, and explore its predictive value for clinical outcomes of elderly aSAH patients. METHODS Between January 2013 and March 2018, 152 elderly aSAH patients were analyzed in this study. Clinical information, imaging findings and laboratory data were reviewed. According to the Glasgow Outcome Scale (GOS), clinical outcomes at 3 months were classified into favorable outcomes (GOS 4-5) and poor outcomes (GOS 1-3). Logistic regression analysis was used to assess the indicators associated with poor outcomes, and receiver curves (ROC) and corresponding area under the curve (AUC) were used to detect the accuracy of the indicator. RESULTS A total of 48 (31.6 %) elderly patients with aSAH had poor outcome at 3 months. In addition to ICH, IVH, Hunt-Hess 4 or 5 Grade and Modified Fisher 3 or 4 Grade, plasma ALT level was also strongly associated with poor outcome of elderly aSAH patients. After adjusting for other covariates, plasma ALT level remained independently associated with pulmonary infection (OR 1.05; 95% CI 1.00-1.09; P = 0.018), cardiac complications (OR 1.05; 95% CI 1.01-1.08; P = 0.014) and urinary infection (OR 1.04; 95% CI 1.00-1.08; P = 0.032). Besides, plasma ALT level had a predictive ability in the occurrence of systemic complications (AUC 0.676; 95% CI: 0.586- 0.766; P<0.001) and poor outcome (AUC 0.689; 95% CI: 0.605-0.773; P<0.001) in elderly aSAH patients. CONCLUSION Plasma ALT level of elderly patients with aSAH was significantly associated with systemic complications, and had additional clinical value in predicting outcomes. Given that plasma ALT levels on admission could help to identify high-risk elderly patients with aSAH, these findings are of clinical relevance.
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Affiliation(s)
- Jianfeng Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, NO.1 of Youyi Rd, Yuzhong District, Chongqing, China
| | - Rui Xu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, NO.1 of Youyi Rd, Yuzhong District, Chongqing, China
| | - Zongduo Guo
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, NO.1 of Youyi Rd, Yuzhong District, Chongqing, China
| | - Xiaochuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, NO.1 of Youyi Rd, Yuzhong District, Chongqing, China
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Hoogmoed J, Coert BA, van den Berg R, Roos YBWEM, Horn J, Vandertop WP, Verbaan D. Early Treatment Decisions in Poor-Grade Patients with Subarachnoid Hemorrhage. World Neurosurg 2018; 119:e568-e573. [PMID: 30077026 DOI: 10.1016/j.wneu.2018.07.212] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) mostly have a poor outcome. Correct identification of patients who might benefit from treatment remains challenging. We investigated which disease-related characteristics, present at admission, could identify patients with chance of good outcome. METHODS In total, 146 consecutive patients with WFNS grade V SAH (2002-2013) were included. Demographic and disease-related characteristics were compared between patients with a good outcome (Glasgow Outcome Scale 4 and 5) and a poor outcome (Glasgow Outcome Scale 1-3). Subgroups were made of patients with aneurysm treatment according to outcome; 1) good outcome; 2) poor outcome, with optimal general treatment; and 3) poor outcome, general treatment discontinued. RESULTS In total, 34 of the 146 patients had a good outcome (36% of all treated patients); 16 (47%) of these presented with a Glasgow Coma Scale score of 3, versus 65 (58%) of patients with a poor outcome (P = 0.33). Eleven (33%) patients in the good outcome group presented with pupillary abnormalities; 4 (12%) even had bilaterally fixed and dilated pupils, versus 49 (46%) in patients with a poor outcome (P < 0.01). In 51 patients, the aneurysm was not treated; all died. CONCLUSIONS More than one third of all treated patients with WFNS grade V SAH had a good outcome. All patients in whom the aneurysm was not treated died. Reliable identification of patients who will reach good outcome, on the basis of symptoms on admission, seems impossible, as these symptoms are not discriminating enough.
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Affiliation(s)
- Jantien Hoogmoed
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands.
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - René van den Berg
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
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Comparison of Aggressive Surgical Treatment and Palliative Treatment in Elderly Patients with Poor-Grade Intracranial Aneurysmal Subarachnoid Hemorrhage. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5818937. [PMID: 29998135 PMCID: PMC5994574 DOI: 10.1155/2018/5818937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/19/2018] [Indexed: 12/29/2022]
Abstract
Objective To compare the current treatment approach in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) and identify the independent predictors of the outcome after aggressive surgical treatment. Method This prospective, multicenter cohort study included 104 poor-grade aneurysmal SAH elderly patients, 60 years or older, treated in our institution from October 2010 to March 2013. Patients were grouped according to three treatment arms. Neurological outcome was assessed using the Glasgow Outcome Scale (GOS) at baseline and at a 12-month follow-up. Univariate and multivariate analysis were performed using the following factors: sex, age, smoking history, breathing ability, alcohol consumption, cerebral hernia, aneurysm location, aneurysm diameter, WFNS grade, CT Fisher grade, treatment approach, and the timing of the aneurysm surgery. Results At the 12-month follow-up, patients in the coiling group and clipping group had better prognosis than patients in the palliative treatment group. Univariate analysis confirmed that the treatment approach, WFNS grade, CT Fisher grade, and age are critical factors for neurological outcomes in poor-grade SAH. Multivariate analysis indicated that WFNS grade V, CT Fisher grades 3-5, and palliative treatment were independent predictors of poor prognoses. Conclusion Aggressive surgical treatment improves the prognoses in poor-grade aneurysm elderly patients with SAH. Elderly Patients of WFNS grade IV and CT Fisher grades 1-2 are more likely to have a better outcome.
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Han Y, Ye F, Long X, Li A, Xu H, Zou L, Yang Y, You C. Ultra-Early Treatment for Poor-Grade Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:e160-e171. [PMID: 29649648 DOI: 10.1016/j.wneu.2018.03.219] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 03/29/2018] [Accepted: 03/30/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND It remains unknown if ultra-early (within 24 hours after onset) treatment can improve the prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). We aimed to evaluate the effect of ultra-early treatment on functional outcomes and mortality in patients with poor-grade aSAH via a systematic review and meta-analysis. METHODS We performed a literature search in the PubMed, MEDLINE, and Web of Science databases. Primary outcomes were death and functional outcome assessed at any time period. Secondary outcomes were the rebleeding rate before an aneurysm occlusion procedure and the incidence of intraoperative technique difficulty (ITD). The results are reported as odds ratio (OR) with 95% confidence interval (CI). RESULTS A total of 14 articles containing 1111 patients met our inclusion criteria and were included in our analysis. The pooled incidence was 47% (95% CI, 40%-54%) for favorable outcome across 13 studies, 26% (95% CI, 19%-32%) for mortality in 11 studies, 10% (95% CI, 3%-16%) for rebleeding in 5 studies, and 20% (95% CI, 10%-31%) for ITD in 5 studies after ultra-early treatment of poor-grade aSAH. Compared with delayed treatment (>24 hours), the ultra-early treatment failed to improve outcomes (OR, 1.23; 95% CI, 0.75-2.01; P = 0.40) or reduce mortality (OR, 0.84; 95% CI, 0.58-1.22; P = 0.45), but tended to prevent preoperative rebleeding (OR, 0.59; 95% CI, 0.32 to 1.07; P = 0.08) in 6, 4, and 4 case-control studies, respectively. CONCLUSIONS Our findings show no significant change both in functional outcome and mortality between ultra-early and delayed treatment although ultra-early treatment may be associated with lower rebleeding rate.
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Affiliation(s)
- Yangyun Han
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China; Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Feng Ye
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Xiaodong Long
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Aiguo Li
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Hong Xu
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Linbo Zou
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Yumin Yang
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China.
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Gobert F, Dailler F, Fischer C, André-Obadia N, Luauté J. Proving cortical death after vascular coma: Evoked potentials, EEG and neuroimaging. Clin Neurophysiol 2018; 129:1105-1116. [PMID: 29621638 DOI: 10.1016/j.clinph.2018.02.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 02/13/2018] [Accepted: 02/24/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Several studies have shown that bilateral abolition of somatosensory evoked potentials after a nontraumatic coma has 100% specificity for nonawakening with ethical consequences for active care withdrawal. We propose to evaluate the prognostic value of bilateral abolished cortical components of SEPs in severe vascular coma. METHODS A total of 144 comatose patients after subarachnoid haemorrhage were evaluated by multimodal evoked potentials (EPs); 7 patients presented a bilateral abolition of somatosensory and auditory EPs. Their prognosis value was interpreted with respect to brainstem auditory EPs, EEG, and structural imaging. RESULTS One patient emerged from vegetative state during follow-up; 6 patients did not return to consciousness. The main neurophysiological difference was a cortical reactivity to pain preserved in the patient who returned to consciousness. This patient had focal sub-cortical lesions, which could explain the abolition of primary cortical components by a bilateral deafferentation of somatosensory and auditory pathways. CONCLUSIONS This is the first report of a favourable outcome after a multimodal abolition of primary cortex EPs in vascular coma. For the 3 cases of vascular coma with preserved brainstem function, EEG reactivity and cortical EPs were abolished by a diffuse ischaemia close to cerebral anoxia. SIGNIFICANCE The complementarity of EPs, EEG, and imaging must be emphasised if therapeutic limitations are considered to avoid over-interpretation of the prognosis value of EPs.
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Affiliation(s)
- Florent Gobert
- Neuro-Intensive Care Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France; University Lyon I, Villeurbanne, France.
| | - Frederic Dailler
- Neuro-Intensive Care Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France
| | - Catherine Fischer
- University Lyon I, Villeurbanne, France; Department of Clinical Neurophysiology, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France
| | - Nathalie André-Obadia
- University Lyon I, Villeurbanne, France; Department of Clinical Neurophysiology, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France
| | - Jacques Luauté
- University Lyon I, Villeurbanne, France; Neuro-Rehabilitation Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France
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Hsieh PC, Wu YM, Wang AYC, Chen CC, Chang CH, Chin SC, Wu TWE, Wu CT, Lee ST. The venous delay phenomenon in computed tomography angiography: a novel imaging outcome predictor for poor cerebral perfusion after severe aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 129:876-882. [PMID: 29171807 DOI: 10.3171/2017.5.jns17794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Diverse treatment results are observed in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). Significant initial perfusion compromise is thought to predict a worse treatment outcome, but this has scant support in the literature. In this cohort study, the authors correlate the treatment outcomes with a novel poor-outcome imaging predictor representing impaired cerebral perfusion on initial CT angiography (CTA). METHODS The authors reviewed the treatment results of 148 patients with poor-grade aSAH treated at a single tertiary referral center between 2007 and 2016. Patients with the "venous delay" phenomenon on initial CTA were identified. The outcome assessments used the modified Rankin Scale (mRS) at the 3rd month after aSAH. Factors that may have had an impact on outcome were retrospectively analyzed. RESULTS Compared with previously identified outcome predictors, the venous delay phenomenon on initial CTA was found to have the strongest correlation with posttreatment outcomes on both univariable (p < 0.0001) and multivariable analysis (OR 4.480, 95% CI 1.565-12.826; p = 0.0052). Older age and a higher Hunt and Hess grade at presentation were other factors that were associated with poor outcome, defined as an mRS score of 3 to 6. CONCLUSIONS The venous delay phenomenon on initial CTA can serve as an imaging predictor for worse functional outcome and may aid in decision making when treating patients with poor-grade aSAH.
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Affiliation(s)
| | | | | | | | - Chien-Hung Chang
- 3Neurology, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Kweishan, Taoyuan, Taiwan
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de Oliveira Manoel AL, Mansur A, Silva GS, Germans MR, Jaja BNR, Kouzmina E, Marotta TR, Abrahamson S, Schweizer TA, Spears J, Macdonald RL. Functional Outcome After Poor-Grade Subarachnoid Hemorrhage: A Single-Center Study and Systematic Literature Review. Neurocrit Care 2017; 25:338-350. [PMID: 27651379 DOI: 10.1007/s12028-016-0305-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Poor-grade subarachnoid hemorrhage (SAH) (World Federation of Neurosurgical Societies grade 4 and 5) is associated with high mortality rates and unfavorable functional outcomes. We report a single-center cohort of poor-grade SAH patients, combined with a systematic review of studies reporting functional outcome in the poor-grade SAH population. METHODS Data on a cohort of poor-grade SAH patients treated between 2009 and 2013 were retrospectively collected and combined with a systematic review (from inception to November 2015; PubMed, Embase). Two reviewers assessed the studies independently based on predefined inclusion criteria: consecutive poor-grade SAH, functional outcome measured at least 3 months after hemorrhage, and the report of patients who died before aneurysm treatment. RESULTS The search yielded 329 publications, and 23 met our inclusion criteria with 2713 subjects enrolled from 1977 to 2014 in 10 countries (including 179 poor-grade patients from our cohort). Mortality rate was 60 % (1683 patients), of which 806 (29 %) died before and 877 (31 %) died after aneurysm treatment, respectively. Treatment was undertaken in 1775 patients (1775/2826-63 %): 1347 by surgical clipping (1347/1775-76 %) and 428 (428/1775-24 %) by endovascular methods. Outcome was favorable in 794 patients (28 %) and unfavorable in 1867 (66 %). When the studies were grouped into decades, favorable outcome increased from 13 % in the late 1970s to early 1980s to 35 % in the late 1980s to early 1990s, and remained unchanged thereafter. CONCLUSION Although mortality remains high in poor-grade SAH patients, a favorable functional outcome can be achieved in approximately one-third of patients. The development of new diagnostic methods and implementation of therapeutic approaches were probably responsible for the decrease in mortality and improvement in the functional outcome from 1970 to the 1990s. The plateau in functional outcome seen thereafter might be explained by the treatment of sicker and older patients and by the lack of new therapeutic interventions specific for SAH.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital, University of Toronto, 3-141 CC, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. .,Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada. .,Neurology and Neurosurgery Department, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Ann Mansur
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Gisele Sampaio Silva
- Neurology and Neurosurgery Department, Universidade Federal de São Paulo, São Paulo, Brazil.,Instituto Israelita de Pesquisa Albert Einstein, Neurology Program, São Paulo, Brazil
| | - Menno R Germans
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Blessing N R Jaja
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada
| | - Ekaterina Kouzmina
- Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital, University of Toronto, 3-141 CC, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Thomas R Marotta
- Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital, University of Toronto, 3-141 CC, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada
| | - Simon Abrahamson
- Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Department of Anesthesiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Tom A Schweizer
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada
| | - Julian Spears
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - R Loch Macdonald
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Post R, Zijlstra IJA, Berg RVD, Coert BA, Verbaan D, Vandertop WP. High-Dose Nadroparin Following Endovascular Aneurysm Treatment Benefits Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2017; 83:281-287. [DOI: 10.1093/neuros/nyx381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 06/13/2017] [Indexed: 12/21/2022] Open
Abstract
Abstract
BACKGROUND
Delayed cerebral ischemia (DCI) is one of the major causes of delayed morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH).
OBJECTIVE
To evaluate the effect of high-dose nadroparin treatment following endovascular aneurysm treatment on the occurrence of DCI and clinical outcome.
METHODS
Medical records of 158 adult patients with an aSAH were retrospectively analyzed. Those patients treated endovascularly for their ruptured aneurysm were included in this study. They received either high-dose (twice daily 5700 AxaIE) or low-dose (once daily 2850 AxaIE) nadroparin treatment after occlusion of the aneurysm. Medical charts were reviewed and imaging was scored by 2 independent neuroradiologists. Data with respect to in-hospital complications, peri-procedural complications, discharge location, and mortality were collected.
RESULTS
Ninety-three patients had received high-dose nadroparin, and 65 patients prophylactic low-dose nadroparin. There was no significant difference in clinical DCI occurrence between patients treated with high-dose (34%) and low-dose (31%) nadroparin. More patients were discharged to home in patients who received high-dose nadroparin (40%) compared to low-dose (17%; odds ratio [OR] 3.13, 95% confidence interval [95% CI]: 1.36-7.24). Furthermore, mortality was lower in the high-dose group (5%) compared to the low-dose group (23%; OR 0.19, 95% CI: 0.07-0.55), also after adjusting for neurological status on admission (OR 0.21, 95% CI: 0.07-0.63).
CONCLUSION
Patients who were treated with high-dose nadroparin after endovascular treatment for aneurysmal SAH were more often discharged to home and showed lower mortality. High-dose nadroparin did not, however, show a decrease in the occurrence of clinical DCI after aSAH. A randomized controlled trial seems warranted.
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Affiliation(s)
- Rene Post
- Neurosurgical Center Amsterdam, Aca-demic Medical Center Amsterdam, the Netherlands
| | | | - Rene van den Berg
- Department of Neurora-diology, Academic Medical Center Amsterdam, the Netherlands
| | - Bert A Coert
- Neurosurgical Center Amsterdam, Aca-demic Medical Center Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Aca-demic Medical Center Amsterdam, the Netherlands
| | - W Peter Vandertop
- Neurosurgical Center Amsterdam, Aca-demic Medical Center Amsterdam, the Netherlands
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Schwartz C, Pfefferkorn T, Ebrahimi C, Ottomeyer C, Fesl G, Bender A, Straube A, Pfister HW, Heck S, Tonn JC, Schichor C. Long-term Neurological Outcome and Quality of Life after World Federation of Neurosurgical Societies Grades IV and V Aneurysmal Subarachnoid Hemorrhage in an Interdisciplinary Treatment Concept. Neurosurgery 2017; 80:967-974. [DOI: 10.1093/neuros/nyw138] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 12/17/2016] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: Detailed data on long-term functional outcome of patients with World Federation of Neurosurgical Societies (WFNS) grades IV and V aneurysmal subarachnoid hemorrhages (aSAH) are still scarce.
OBJECTIVE: Assessment of long-term outcome of WFNS IV and V aSAH patients.
METHODS: Functional outcome and quality of life were assessed by the modified Rankin scale (mRS) and the 36-item short-form health survey in consecutively treated aSAH WFNS IV and V patients between 2005 and 2010. Scores from the 36-item short-form health survey were compared to a healthy German population. Prognostic factors were analyzed by uni- and multivariate models.
RESULTS: One hundred and seven eligible patients (median age: 53.0 years) were identified. After interdisciplinary consensus on optimal treatment, aneurysms were obliterated either by clipping (n = 35) or by coiling (n = 72). Ten patients were lost to long-term follow-up; the median clinical follow-up period was 3.2 years for the remaining 97 cases. Twenty-five of 97 died during the acute hospital phase and another 10 patients over the follow-up period leaving 62 long-term survivors. At the end of clinical follow-up, 40/97 patients, including 40/62 of long-term survivors, reached functional independence (mRS ≤ 2). Twelve of 97 patients were moderately (mRS = 3), 10/97 patients were severely disabled (mRS ≥ 4). Younger age (≤ 53 years; P = .001) and radiological absence of cerebral infarction (P = .03) were the strongest predictors for favorable outcome. Quality of life was perceived to be only moderately reduced compared to the healthy control group.
CONCLUSION: Poor-grade aSAH is not necessarily associated with poor long-term functional outcome; after aneurysm repair ∼60% of patients survived and among long-term survivors ∼ 60% regained functional independence.
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Affiliation(s)
- Christoph Schwartz
- Department of Neurosurgery, Ludwig- Maximilians-University, Munich, Germ-any
| | - Thomas Pfefferkorn
- Department of Ne-urology, Ludwig-Maximilians-University, Munich, Germany
| | - Caroline Ebrahimi
- Department of Ne-urology, Ludwig-Maximilians-University, Munich, Germany
| | - Caroline Ottomeyer
- Department of Ne-urology, Ludwig-Maximilians-University, Munich, Germany
| | - Gunther Fesl
- Institute of Neuroradiology, Ludwig-Maximilians-University, Munich, Germany
| | - Andreas Bender
- Department of Ne-urology, Ludwig-Maximilians-University, Munich, Germany
| | - Andreas Straube
- Department of Ne-urology, Ludwig-Maximilians-University, Munich, Germany
| | | | - Suzette Heck
- Department of Ne-urology, Ludwig-Maximilians-University, Munich, Germany
| | - Jörg-Christian Tonn
- Department of Neurosurgery, Ludwig- Maximilians-University, Munich, Germ-any
| | - Christian Schichor
- Department of Neurosurgery, Ludwig- Maximilians-University, Munich, Germ-any
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Hoogmoed J, van den Berg R, Coert BA, Rinkel GJE, Vandertop WP, Verbaan D. A strategy to expeditious invasive treatment improves clinical outcome in comatose patients with aneurysmal subarachnoid haemorrhage. Eur J Neurol 2016; 24:82-89. [PMID: 27670264 DOI: 10.1111/ene.13134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with poor clinical condition after aneurysmal subarachnoid haemorrhage (aSAH), treatment is often deferred until patients show signs of improvement. Early external ventricular drainage and aneurysm occlusion may improve prognosis also in poor grade patients. The clinical outcome of an expeditious approach was compared with that of a conservative approach. METHODS In all, 285 consecutive World Federation of Neurological Surgeons (WFNS) grade V aSAH patients admitted to three university hospitals between January 2000 and June 2007 were included. Two hospitals followed an expeditious approach, one a more conservative approach. Groups were compared with respect to demographic and clinical characteristics and outcome. Univariable and multivariable analyses were performed to determine the associations with good outcome (Glasgow Outcome Scale scores 4-5), using logistic regression models. RESULTS Good outcome was seen more often in expeditiously treated patients [22% vs. 11%; odds ratio (OR) 2.24, 95% confidence interval (CI) 1.17-4.27]. Expeditiously treated patients more often underwent aneurysm occlusion than conservatively treated patients (64% vs. 27%; OR 4.86, 95% CI 2.93-8.05) and placement of an external ventricular catheter (82% vs. 31%; OR 10.05, CI 5.72-10.66). There was no significant difference in rebleeding between patient groups. Occlusion of the aneurysm was the only variable that remained significant in the multivariable model with an OR of 43.73 (95% CI 10.34-184.97). CONCLUSIONS An expeditious invasive treatment strategy in WFNS grade V aSAH patients can lead to a better outcome. Hesitance in the early stages seems a self-fulfilling prophecy for a poor outcome.
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Affiliation(s)
- J Hoogmoed
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - R van den Berg
- Department of Neuroradiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - B A Coert
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - G J E Rinkel
- Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - W P Vandertop
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - D Verbaan
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
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Fung C, Inglin F, Murek M, Balmer M, Abu-Isa J, Z’Graggen WJ, Ozdoba C, Gralla J, Jakob SM, Takala J, Beck J, Raabe A. Reconsidering the logic of World Federation of Neurosurgical Societies grading in patients with severe subarachnoid hemorrhage. J Neurosurg 2016; 124:299-304. [DOI: 10.3171/2015.2.jns14614] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Current data show a favorable outcome in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) Grade V subarachnoid hemorrhage (SAH) and a rather poor prediction of worst cases. Thus, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. One reason for this lack of differentiation is the use of “negative” or “silent” diagnostic signs as part of the WFNS Grade V definition. The authors therefore reevaluated the WFNS scale by using “positive” clinical signs and the logic of the Glasgow Coma Scale as a progressive herniation score.
METHODS
The authors performed a retrospective analysis of 182 patients with SAH who had poor grades on the WFNS scale. Patients were graded according to the original WFNS scale and additionally according to a modified classification, the WFNS herniation (hWFNS) scale (Grade IV, no clinical signs of herniation; Grade V, clinical signs of herniation). The prediction of poor outcome was compared between these two grading systems.
RESULTS
The positive predictive values of Grade V for poor outcome were 74.3% (OR 3.79, 95% CI 1.94–7.54) for WFNS Grade V and 85.7% (OR 8.27, 95% CI 3.78–19.47) for hWFNS Grade V. With respect to mortality, the positive predictive values were 68.3% (OR 3.9, 95% CI 2.01–7.69) for WFNS Grade V and 77.9% (OR 6.22, 95% CI 3.07–13.14) for hWFNS Grade V.
CONCLUSIONS
Limiting WFNS Grade V to the positive clinical signs of the Glasgow Coma Scale such as flexion, extension, and pupillary abnormalities instead of including “no motor response” increases the prediction of mortality and poor outcome in patients with severe SAH.
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Affiliation(s)
| | | | | | | | | | | | - Christoph Ozdoba
- 2Institute for Diagnostic and Interventional Neuroradiology, and
| | - Jan Gralla
- 2Institute for Diagnostic and Interventional Neuroradiology, and
| | - Stephan M. Jakob
- 3Department of Intensive Care Medicine, Bern University Hospital (Inselspital) and University of Bern, Switzerland
| | - Jukka Takala
- 3Department of Intensive Care Medicine, Bern University Hospital (Inselspital) and University of Bern, Switzerland
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de Oliveira Manoel AL, Goffi A, Marotta TR, Schweizer TA, Abrahamson S, Macdonald RL. The critical care management of poor-grade subarachnoid haemorrhage. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:21. [PMID: 26801901 PMCID: PMC4724088 DOI: 10.1186/s13054-016-1193-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Aneurysmal subarachnoid haemorrhage is a neurological syndrome with complex systemic complications. The rupture of an intracranial aneurysm leads to the acute extravasation of arterial blood under high pressure into the subarachnoid space and often into the brain parenchyma and ventricles. The haemorrhage triggers a cascade of complex events, which ultimately can result in early brain injury, delayed cerebral ischaemia, and systemic complications. Although patients with poor-grade subarachnoid haemorrhage (World Federation of Neurosurgical Societies 4 and 5) are at higher risk of early brain injury, delayed cerebral ischaemia, and systemic complications, the early and aggressive treatment of this patient population has decreased overall mortality from more than 50% to 35% in the last four decades. These management strategies include (1) transfer to a high-volume centre, (2) neurological and systemic support in a dedicated neurological intensive care unit, (3) early aneurysm repair, (4) use of multimodal neuromonitoring, (5) control of intracranial pressure and the optimisation of cerebral oxygen delivery, (6) prevention and treatment of medical complications, and (7) prevention, monitoring, and aggressive treatment of delayed cerebral ischaemia. The aim of this article is to provide a summary of critical care management strategies applied to the subarachnoid haemorrhage population, especially for patients in poor neurological condition, on the basis of the modern concepts of early brain injury and delayed cerebral ischaemia.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada. .,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Alberto Goffi
- Toronto Western Hospital MSNICU, 2nd Floor McLaughlin Room 411-H, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Tom R Marotta
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Tom A Schweizer
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Simon Abrahamson
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - R Loch Macdonald
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
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Schuss P, Hadjiathanasiou A, Borger V, Wispel C, Vatter H, Güresir E. Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Factors Influencing Functional Outcome—A Single-Center Series. World Neurosurg 2016; 85:125-9. [DOI: 10.1016/j.wneu.2015.08.046] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022]
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Howard BM, Barrow DL. Outcomes for Patients with Poor-Grade Subarachnoid Hemorrhage: To Treat or Not To Treat? World Neurosurg 2015; 86:30-2. [PMID: 26498399 DOI: 10.1016/j.wneu.2015.10.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 10/15/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Brian M Howard
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Daniel L Barrow
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
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Effect of triple-h prophylaxis on global end-diastolic volume and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2015; 21:462-9. [PMID: 24865266 DOI: 10.1007/s12028-014-9973-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although prophylactic triple-H therapy has been used in a number of institutions globally to prevent delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH), limited evidence is available for the effectiveness of triple-H therapy on hemodynamic variables. Recent studies have suggested an association between low global end-diastolic volume index (GEDI), measured using a transpulmonary thermodilution method, and DCI onset. The current study aimed at assessing the effects of prophylactic triple-H therapy on GEDI. METHODS This prospective multicenter study included aneurysmal SAH patients admitted to 9 hospitals in Japan. The decision to administer prophylactic triple-H therapy and the management protocols were left to the physician in charge (physician-directed therapy) of each participating institution. The primary endpoints were the changes in the hemodynamic variables as analyzed using a generalized linear mixed model. RESULTS Of 178 patients, 62 (34.8 %) received prophylactic triple-H therapy and 116 (65.2 %) did not. DCI was observed in 35 patients (19.7 %), with no significant difference between the two groups [15 (24.2 %) vs. 20 (17.2 %), p = 0.27]. Although a greater amount of fluid (p < 0.001) and a higher mean arterial pressure (p = 0.005) were observed in the triple-H group, no significant difference was observed between the groups in GEDI (p = 0.81) or cardiac output (p = 0.62). CONCLUSIONS Physician-directed prophylactic triple-H administration was not associated with improved clinical outcomes or quantitative hemodynamic indicators for intravascular volume. Further, GEDI-directed intervention studies are warranted to better define management algorithms for SAH patients with the aim of preventing DCI.
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Zhao B, Zhao Y, Tan X, Cao Y, Wu J, Zhong M, Wang S. Factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage: a multicentre retrospective analysis. BMJ Open 2015; 5:e007410. [PMID: 25877280 PMCID: PMC4401840 DOI: 10.1136/bmjopen-2014-007410] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To determine factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage (aSAH). DESIGN A multicentre retrospective analysis, observational study. SETTING High-volume teaching hospitals (more than 150 aSAH cases per year). PARTICIPANTS 118 patients with World Federation of Neurosurgical Societies (WFNS) grades IV and V underwent surgical treatment. Ultra-early surgery was defined as surgery performed within 24 h of aSAH, and delayed surgery as surgery performed after 24 h. Outcome was assessed by modified Rankin Scale (mRS). The mean time of follow-up was 12.5±3.4 months (range 6-28 months). RESULTS 47 (40%) patients underwent ultra-early surgery, and 71 (60%) patients underwent delayed surgery. Patients with WFNS grade V (p=0.011) and brain herniation (p=0.004) more often underwent ultra-early surgery. Postoperative complications were similar in ultra-early and delayed surgery groups. Adjusted multivariate analysis showed the outcomes were similar between the two groups. Multivariate analysis of predictors of poor outcome, ultraearly surgery was not an independent predictor of poor outcome, while advanced age, postresuscitation WFNS V grade, intraventricular haemorrhage, brain herniation and non-middle cerebral artery (MCA) aneurysms were associated with poor outcome. CONCLUSIONS Although patients with WFNS grade V and brain herniation more often undergo ultra-early surgery, postoperative complications and outcomes in selected patients were similar in the two groups. Patients of younger age, WFNS grade IV, absence of intraventricular haemorrhage, absence of brain herniation and MCA aneurysms are more likely to have a good outcome. Ultra-early surgery could improve outcomes in carefully selected patients with poor-grade aSAH.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Xianxi Tan
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
| | - Ming Zhong
- Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China
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Fung C, Balmer M, Murek M, Z'Graggen WJ, Abu-Isa J, Ozdoba C, Haenggi M, Jakob SM, Raabe A, Beck J. Impact of early-onset seizures on grading and outcome in patients with subarachnoid hemorrhage. J Neurosurg 2015; 122:408-13. [DOI: 10.3171/2014.10.jns14163] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
After subarachnoid hemorrhage (SAH), seizure occurs in up to 26% of patients. The impact of seizure on outcome has been studied, yet its impact on grading is unknown. The authors evaluated the impact of early-onset seizures (EOS) on grading of spontaneous SAH and on outcome.
METHODS
This retrospective analysis included consecutive patients with SAH who were treated at the NeuroCenter, Inselspital, University Hospital Bern, Switzerland, between January 2005 and December 2010. Demographic data, clinical data, and reports of EOS were recorded. The EOS were defined as seizures occurring within 24 hours after ictus. Patients were graded according to the World Federation of Neurosurgical Societies (WFNS) scale pre- and postresuscitation and dichotomized into good (WFNS I–III) and poor (WFNS IV–V) grades. Outcome was assessed at 6 months by using the modified Rankin Scale (mRS); an mRS score of 0–3 was considered a good outcome and an mRS score of 4–6 was considered a poor outcome.
RESULTS
Forty-one of 425 patients with SAH had EOS. Twenty-seven of those 41 patients (65.9%) had a poor WFNS grade. Twenty-eight (68.3%) achieved a good outcome, 11 (26.8%) had a poor outcome, and 2 (4.9%) were lost to followup. Early-onset seizures were proven in 9 of 16 electroencephalograms. The EOS were associated with poor WFNS grade (OR 2.81, 97.5% CI 1.14–7.46; p = 0.03) and good outcome (OR 4.01, 97.5% CI 1.63–10.53; p = 0.03). Increasing age, hydrocephalus, intracerebral hemorrhage, and intraventricular hemorrhage were associated with poor WFNS grade, whereas only age, intracerebral hemorrhage (p < 0.001), and poor WFNS grade (p < 0.001) were associated with poor outcome.
CONCLUSIONS
Patients with EOS were classified significantly more often in a poor grade initially, but then they significantly more often achieved a good outcome. The authors conclude that EOS can negatively influence grading. This might influence decision making for the care of patients with SAH, so grading of patients with EOS should be interpreted with caution.
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Affiliation(s)
| | | | | | | | | | - Christoph Ozdoba
- 3Institute for Diagnostic and Interventional Neuroradiology, and
| | - Matthias Haenggi
- 4Department of Intensive Care Medicine, University Hospital (Inselspital) and University of Bern, Switzerland
| | - Stephan M. Jakob
- 4Department of Intensive Care Medicine, University Hospital (Inselspital) and University of Bern, Switzerland
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Sorimachi T, Osada T, Aoki R, Nishiyama J, Hirayama A, Srivatanakul K, Matsumae M. Density of the cerebral cortex in computed tomography angiography source images and clinical outcomes in Grade V subarachnoid hemorrhage. Neurol Res 2015; 37:484-90. [DOI: 10.1179/1743132815y.0000000001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
BACKGROUND Prognostication of mortality or severe disability often prompts withdrawal of technological life support in patients following aneurysmal subarachnoid hemorrhage (aSAH). We assessed admission factors impacting decisions to withdraw treatment after aSAH. METHODS Prospectively collected data of aSAH patients admitted to our institution between 1991 and 2009 were reviewed. Patients given comfort care measures were identified, including early withdrawal of treatment (<72 h after admission). Independent predictors of treatment withdrawal were assessed with multivariable analysis. RESULTS The study included 1,134 patients, of whom 72 % were female, 58 % white, and 38 % black or African-American. Mean age was 52.5 ± 14.0 years. In-hospital mortality was 18.3 %. Of the 207 patients who died, treatment was withdrawn in 72 (35 %) and comfort measures instituted early in 31 (15 %). Among patients who died, WOLST was associated with older age (63.6 ± 14.2 years, WOLST vs. 55.6 ± 13.7 years, no WOLST, p < 0.001); GCS score <8 (62 % of WOLST vs. 44 % with no WOLST, p = 0.010); HH >3 (72 % of WOLST vs. 53 % with no WOLST, p = 0.008); and hydrocephalus (81 % of WOLST vs. 63 % with no WOLST, p = 0.009). Independent predictors of WOLST were poorer Hunt and Hess grade (AOR 1.520, 95 % CI 1.160-1.992, p = 0.002) and older age (AOR 1.045, 95 % CI 1.022-1.068, p < 0.001) with the latter also impacting early WOLST decisions. CONCLUSIONS Older age and poor clinical grade on presentation predicted WOLST, and age predicted decisions to withdraw treatment earlier following aSAH. While based on prognosis, and in some cases patient wishes, this may also constitute a self-fulfilling prophecy in others.
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Optimal range of global end-diastolic volume for fluid management after aneurysmal subarachnoid hemorrhage: a multicenter prospective cohort study. Crit Care Med 2014; 42:1348-56. [PMID: 24394632 DOI: 10.1097/ccm.0000000000000163] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Limited evidence supports the use of hemodynamic variables that correlate with delayed cerebral ischemia or pulmonary edema after aneurysmal subarachnoid hemorrhage. The aim of this study was to identify those hemodynamic variables that are associated with delayed cerebral ischemia and pulmonary edema after subarachnoid hemorrhage. DESIGN A multicenter prospective cohort study. SETTING Nine university hospitals in Japan. PATIENTS A total of 180 patients with aneurysmal subarachnoid hemorrhage. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were prospectively monitored using a transpulmonary thermodilution system in the 14 days following subarachnoid hemorrhage. Delayed cerebral ischemia was developed in 35 patients (19.4%) and severe pulmonary edema was developed in 47 patients (26.1%). Using the Cox proportional hazards model, the mean global end-diastolic volume index (normal range, 680-800 mL/m) was the independent factor associated with the occurrence of delayed cerebral ischemia (hazard ratio, 0.74; 95% CI, 0.60-0.93; p = 0.008). Significant differences in global end-diastolic volume index were detected between the delayed cerebral ischemia and non-delayed cerebral ischemia groups (783 ± 25 mL/m vs 870 ± 14 mL/m; p = 0.007). The global end-diastolic volume index threshold that best correlated with delayed cerebral ischemia was less than 822 mL/m, as determined by receiver operating characteristic curves. Analysis of the Cox proportional hazards model indicated that the mean global end-diastolic volume index was the independent factor that associated with the occurrence of pulmonary edema (hazard ratio, 1.31; 95% CI, 1.02-1.71; p = 0.03). Furthermore, a significant positive correlation was identified between global end-diastolic volume index and extravascular lung water (r = 0.46; p < 0.001). The global end-diastolic volume index threshold that best correlated with severe pulmonary edema was greater than 921 mL/m. CONCLUSIONS Our findings suggest that global end-diastolic volume index impacts both delayed cerebral ischemia and pulmonary edema after subarachnoid hemorrhage. Maintaining global end-diastolic volume index slightly above normal levels has promise as a fluid management goal during the treatment of subarachnoid hemorrhage.
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Prunet B, Basely M, D'Aranda E, Cambefort P, Pons F, Cimarelli S, Dagain A, Desse N, Veyrieres JB, Jego C, Lacroix G, Esnault P, Boret H, Goutorbe P, Bussy E, Habib G, Meaudre E. Impairment of cardiac metabolism and sympathetic innervation after aneurysmal subarachnoid hemorrhage: a nuclear medicine imaging study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R131. [PMID: 24964817 PMCID: PMC4230019 DOI: 10.1186/cc13943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 06/13/2014] [Indexed: 12/11/2022]
Abstract
Introduction Although aneurysmal subarachnoid hemorrhage (SAH) is often complicated by myocardial injury, whether this neurogenic cardiomyopathy is associated with the modification of cardiac metabolism is unknown. This study sought to explore, by positron emission tomography/computed tomography, the presence of altered cardiac glucose metabolism after SAH. Methods During a 16-month period, 30 SAH acute phase patients underwent myocardial 18 F- fluorodesoxyglucose positron emission tomography (18F-FDGPET), 99mTc-tetrofosmin and 123I-meta-iodobenzylguanidine (123I-mIBG) scintigraphy, respectively, assessing glucose metabolism, cardiac perfusion, and sympathetic innervation. Patients with initial abnormalities were followed monthly for two months for 18F-FDG, and six months later for 123I-mIBG. Results In this SAH population, acute cardiac metabolic disturbance was observed in 83% of patients (n = 25), and sympathetic innervation disturbance affected 90% (n = 27). Myocardial perfusion was normal for all patients. The topography and extent of metabolic defects and innervation abnormalities largely overlapped. Follow-up showed rapid improvement of glucose metabolism in one or two months. Normalization of sympathetic innervation was slower; only 27% of patients (n = 8) exhibited normal 123I-mIBG scintigraphy after six months. Presence of initial altered cardiac metabolism was not associated with more unfavorable cardiac or neurological outcomes. Conclusions These findings support the hypothesis of neurogenic myocardial stunning after SAH. In hemodynamically stable acute phase SAH patients, cardiomyopathy is characterized by diffuse and heterogeneous 18F-FDG and 123I-mIBG uptake defect. Trial registration Clinicaltrials.gov NCT01218191. Registered 6 October 2010.
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