Long-term subarachnoid haemorrhage survivors still die due to cerebrovascular causes

Prognostic value of the systemic inflammation response index in patients with aneurismal subarachnoid hemorrhage and a Nomogram model construction

OBJECTIVE

To investigate the prognostic value of inflammatory markers, including neutrophil/lymphocyte ratio (NLR), derived neutrophil/lymphocyte ratio (dNLR), platelet/lymphocyte ratio (PLR), monocyte/lymphocyte ratio (MLR), prognostic nutritional index (PNI), and systemic inflammation response index (SIRI) in patients with aneurismal subarachnoid hemorrhage (aSAH), and then develop a Nomogram prognostic model.

METHODS

We analysed 178 aSAH patients who underwent surgery at Subei People's Hospital of Jiangsu province from January 2015 to December 2017. Patients were divided into two groups according to Glasgow outcome scale (GOS) score at 3 months. Univariate and multivariate analysis were used to identify the association between inflammatory markers and prognosis. Subsequently, we identified the best cutoff of SIRI for unfavorable outcome using receiver operating characteristic (ROC) curve analysis and compared the clinical data between high and low SIRI levels. We further evaluated the additive value of SIRI by comparing prognostic nomogram models with and without it.

RESULTS

A total of 47 (26.4%) patients had a poor outcome. Multivariate logistic regression analysis showed that SIRI was an independent risk factor of poor outcome. The SIRI of 4.105 × 109/L was identified as the optimal cutoff value, patients with high SIRI levels had worse clinical status and higher rates of unfavorable outcome. ROC analysis showed that a nomogram model combining the SIRI and other conventional factors showed more favorable predictive ability than the model without the SIRI.

CONCLUSIONS

SIRI was independently correlated with unfavorable outcome in SAH patients, and the nomogram model combining the SIRI had more favorable discrimination ability.

The impact of previous health on the mortality after aneurysmal subarachnoid hemorrhage: analysis of a prospective Swedish multicenter study

PURPOSE

There is an an increasing awareness of the importance of health and lifestyle for stroke diseases like spontaneous subarachnoid hemorrhage (SAH). However, the importance of pre-existing medical conditions for clinical course and mortality after SAH has not been studied. The aim of the present study was to identify pre-existing conditions contributing to mortality after SAH.

METHODS

Data were extracted from a Swedish national prospective study on patients with SAH. Variables were defined for age, sex, body mass index (BMI), clinical condition at admission, and for 10 pre-existing medical conditions. Models predicting mortality in three time intervals with all possible subsets of these variables were generated, compared and selected using Akaike's information criterion.

RESULTS

1155 patients with ruptured aneurysms were included. The mortality within 1 week was 7.6%, 1 month 14.3%, and 1 year 18.7%. The most common pre-existing medical conditions were smoking (57.6%) and hypertension (38.7%). The model's best predicting mortality within 1 week and from 1 week to 1 month included only the level of consciousness at admission and age, and these two variables were present in all the models among the top 200 in Akaike score for each time period. The most predictive model for mortality between 1 month and 1 year added previous stroke, diabetes, psychiatric disease, and BMI as predictors.

CONCLUSION

Mortality within the first month was best predicted simply by initial level of consciousness and age, while mortality within from 1 month to 1 year was significantly influenced by pre-existing medical conditions.

Comprehensive analysis of immune cell infiltration and role of MSR1 expression in aneurysmal subarachnoid haemorrhage

Aneurysmal subarachnoid haemorrhage (aSAH), resulting from the rupture of intracranial aneurysms, can yield high mortality and disability. This study aimed to explore the immune infiltration of aneurysmal tissues and investigate a novel mechanism underlying aSAH. We downloaded datasets containing expression profiles of aneurysmal and normal arterial tissues from the online database. Then a comprehensive bioinformatic strategy was conducted to select the biomarkers of aneurysmal tissues. Two calculation algorithms were performed to identify the unique immune characteristics between aneurysmal tissues and normal arteries. Double immunofluorescence staining was used to investigate the role of pathway-related proteins in the inflammatory process after aSAH. Six microarray datasets were integrated, and another RNA-sequencing dataset was used as the validation dataset. Functional enrichment analysis of the differentially expressed genes indicated that immune-related processes were closely related to the progression of aSAH. We then performed immune microenvironment infiltration analysis, and the results suggested macrophages were abnormally enriched in aneurysmal tissues. Core gene MSR1 was filtered through a comprehensive bioinformatic strategy. Our analysis suggested that MSR1 might be associated with macrophage activation and migration. Our study elucidated the impact of macrophage and MSR1 on aSAH progression. These findings were helpful in gaining insight into the immune heterogeneity of aneurysmal tissues and normal arteries, and in identifying patients who might benefit from immunotherapy.

Management of Aneurysmal Subarachnoid Hemorrhage: Variation in Clinical Practice and Unmet Need for Follow-up among Survivors-A Single-Center Perspective

OBJECTIVE

The purpose of the present study is to investigate the existence and/or prevalence of clinical practice variation in management of aneurysmal subarachnoid hemorrhage (aSAH) and to determine the need for long-term follow-up.

METHODS

A single-center study was carried out of patients with aSAH over a 5-year period divided into 2 halves (2.5 years each) before and after addition of a dually trained cerebrovascular neurosurgeon. In-hospital clinical practice, clinical outcome (mortality and discharge destination) and long-term outcome (modified Rankin Scale score and Telephone Interview for Cognitive Status [TICS]) were compared using descriptive summaries and nonparametric tests.

RESULTS

Among 251 patients admitted with aSAH, 115 (45.8%) were before the index event, whereas 136 (54.2%) were during the later period. The aneurysm-securing procedure changed from coil embolization to clip ligation (12/115 [10.4%] vs. 84/136 [61.8%]; P < 0.0001) during the latter years. Interventional treatment for cerebral vasospasm has decreased (58/115 [50.4%] vs. 49/136 [36.0%]; P = 0.0002). Patients surviving hospitalization had more clinic follow-up after discharge during the latter period (42/85 [49.4%] vs. 76/105 [72.4%]; P = 0.0012) and ventriculoperitoneal shunt placement for delayed hydrocephalus (1/85 [1.2%] vs. 9/105 [8.6%]; P = 0.02). A subcohort of aSAH survivors (n = 46) had lower median TICS score during the earlier study period (31.5 [interquartile range, 22-36] vs. 33 [interquartile range, 27-38]; P = 0.038). Similarly, preictal smoking status and hyperlipidemia were associated with adverse TICS score in a multivariate model (P = 0.007).

CONCLUSIONS

Postdischarge clinical follow-up has improved facilitating recognition and treatment of delayed hydrocephalus. Existence of cognitive deficits among survivors calls for establishment of multidisciplinary clinics for long-term management of aSAH.

Impact of Acute Cardiac Complications After Subarachnoid Hemorrhage on Long-Term Mortality and Cardiovascular Events

Background

Cardiac complications frequently occur after subarachnoid hemorrhage (SAH) and are associated with an increased risk of neurological complications and poor outcomes. The aim of this study was to evaluate the impact of acute cardiac complications after SAH on long-term mortality and cardiovascular events.

Methods

All patients admitted to our Neuro intensive care unit with verified SAH from January 2010 to April 2015, and electrocardiogram, echocardiogram, and troponin T or NTproBNP data obtained within 72 h of admission were included in the study. Mortality data were obtained from the Swedish population register. Data regarding cause of death and hospitalization for cardiovascular events were obtained from the Swedish Board of Health and Welfare.

Results

A total of 455 patients were included in the study analysis. There were 102 deaths during the study period. Cardiac troponin release (HR 1.08, CI 1.02–1.15 per 100 ng/l, p = 0.019), NTproBNP (HR 1.05, CI 1.01–1.09 per 1000 ng/l, p = 0.018), and ST-T abnormalities (HR 1.53, CI 1.02–2.29, p = 0.040) were independently associated with an increased risk of death. However, these associations were significant only during the first 3 months after the hemorrhage. Cardiac events were observed in 25 patients, and cerebrovascular events were observed in 62 patients during the study period. ST-T abnormalities were independently associated with an increased risk of cardiac events (HR 5.52, CI 2.07–14.7, p < 0.001), and stress cardiomyopathy was independently associated with an increased risk of cerebrovascular events (HR 3.65, CI 1.55–8.58, p = 0.003).

Conclusion

Cardiac complications after SAH are associated with an increased risk of short-term death. Patients with electrocardiogram abnormalities and stress cardiomyopathy need appropriate follow-up for the identification of cardiac disease or risk factors for cardiovascular disease.

Electronic supplementary material

The online version of this article (10.1007/s12028-018-0558-0) contains supplementary material, which is available to authorized users.

Is Admission Lipoprotein-Associated Phospholipase A2 a Novel Predictor of Vasospasm and Outcome in Patients With Aneurysmal Subarachnoid Hemorrhage?

BACKGROUND

The relationships between lipoprotein-associated phospholipase A2 (Lp-PLA2) level, vasospasm, and clinical outcome of patients with aneurysmal subarachnoid hemorrhage (aSAH) are still unclear.

OBJECTIVE

To identify the associations between admission Lp-PLA2 and vasospasm following subarachnoid hemorrhage and the clinical outcome of aSAH.

METHODS

A total of 103 aSAH patients who had Lp-PLA2 level obtained within 24 h postbleeding were included. The relationships between Lp-PLA2 level, vasospasm, and clinical outcome were analyzed.

RESULTS

Vasospasm was observed in 52 patients (50.49%). Patients with vasospasm had significantly higher Lp-PLA2 level than those without (P &lt; .001). Both modified Fisher grade (P = .014) and Lp-PLA2 level (P &lt; .001) were significant predictors associated with vasospasm. The Z test revealed that power of Lp-PLA2 was significantly higher than that of modified Fisher grade in predicting vasospasm (Z = 2.499, P = .012). At 6-mo follow-up, 44 patients (42.72%) had unfavorable outcome and 36 patients (34.95%) died. The World Federation of Neurosurgical Societies (WFNS) grade and Lp-PLA2 level were both significant predictors associated with 6-mo unfavorable outcome and mortality (all P &lt; .001). The predictive values of Lp-PLA2 for unfavorable outcome and mortality at 6-mo tended to be lower than those of the WFNS grade, but the differences were not statistically significant (P = .366 and 0.115, respectively). Poor-grade patients having Lp-PLA2 &gt; 200 μg/L had significantly worse 6-mo survival rate than poor-grade patients having Lp-PLA2 ≤ 200 μg/L (P = .001).

CONCLUSION

The Lp-PLA2 might be useful as a novel predictor in aSAH patients. A total of 30 poor-grade patients; those with elevated Lp-PLA2 level have higher risk of 6-mo mortality compared to those without.

Neuroglobin as a Novel Biomarker for Predicting Poor Outcomes in Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

Neuroglobin (Ngb) has a high affinity for oxygen and helps prevent hypoxic-ischemic brain damage. In this study we analyzed the relationship between Ngb levels and clinical outcomes of aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Serum Ngb levels were measured in 58 patients with aSAH and 27 control individuals using the enzyme-linked immunosorbent assay. To continuously assess aSAH, we measured serum Ngb levels on days 1, 2, 3, 5, and 7 after aSAH. Clinical data were collected using the Hunt and Hess Scale, the Glasgow Coma Scale (GCS), the World Federation of Neurological Surgeons (WFNS) Scale, and the modified Fisher Scale. Clinical outcomes included 6-month mortality and 6-month unfavorable outcomes (modified Rankin Scale (mRS) score of 3-6).

RESULTS

Serum Ngb levels increased after aSAH, peaked on day 2, and then gradually decreased. Serum Ngb levels on admission were higher in the patient group than in the control group (7.67 ± 2.56 ng/mL vs. 6.45 ± 0.88 ng/mL, P < 0.05). Multivariate logistic regression analysis indicated that serum Ngb levels on day 2 after aSAH were independently related to 6-month mortality (odds ratio [OR] = 0.265, 95% confidence interval [CI] = 0.094-0.747, P < 0.05) and 6-month unfavorable outcomes (OR = 1.919, 95% CI = 1.158-3.180, P < 0.05), and receiver operating characteristic curve analysis showed that serum Ngb levels on day 2 predicted 6-month mortality and 6-month unfavorable outcomes, with areas under the curve of 0.893 (P < 0.05; 95% CI, 0.812-0.974) and 0.818 (P < 0.05; 95% CI, 0.691-0.954), respectively, based on the best thresholds.

CONCLUSIONS

Serum Ngb levels on day 2 after aSAH were strongly associated with poor outcomes in aSAH, suggesting that Ngb may be a novel biomarker for predicting poor outcomes in aSAH.

Life situation 5 years after subarachnoid haemorrhage

OBJECTIVES

Subarachnoid haemorrhage (SAH) has high mortality and morbidity among survivors. SAH mainly affects young people and may result in long-term disabilities such as decreased Health-related Quality of Life (HRQoL), mental health and cognitive function. The aim of this study was to investigate the life situation 5 years after a SAH including physical/emotional status, participation and HRQoL.

MATERIALS & METHODS

In this cross-sectional descriptive study, a mail survey was sent to all persons treated at a neurosurgery unit in Gothenburg, Sweden, for non-traumatic SAH in 2009-2010, approximately 5 years post-SAH. The survey included questions regarding HRQoL; EuroQol 5-Dimensions (EQ-5D), the impact of the SAH; Stroke Impact Scale (SIS), Occupational Gaps Questionnaire and participation in society; Impact of Participation and Autonomy (IPA).

RESULTS

Forty-two 5 year survivors were sent the survey, of whom 26 (62%) responded (59 years old, range 33-85). The participants had generally low HRQoL and scored low in the domain of anxiety and depression. Many reported problems with emotions, fatigue, memory and executive function, but few problems with physical condition. However, nearly all participants reported to have an acceptable level of participation and 64% were independent in their daily life.

CONCLUSIONS

In this 5-year follow-up after SAH, the participants reported to have a greater number of hidden disabilities compared to physical problems, whereas most had acceptable participation in society. A yearly follow-up after a SAH could be suggested aiming to improving the cognitive and mental health.

Serum mannose-binding lectin levels after aneurysmal subarachnoid hemorrhage

BACKGROUND

Mannose-binding lectin (MBL) is a key molecule of complement system, which is activated after aneurysmal subarachnoid hemorrhage (aSAH). We investigated the association of serum MBL levels with injury severity and clinical outcomes among aSAH patients.

MATERIALS AND METHODS

Serum MBL levels were determined in 132 aSAH patients and 132 controls. We assessed the association of serum MBL levels with 6-month mortality and unfavorable outcome (Glasgow Outcome Scale score, 1-3) and injury severity reflected by World Federation of Neurological Surgeons (WFNS) scores and modified Fisher scores. Factors found significant on univariate analysis were further tested on a multivariate model. Meantime, the prognostic predictive values were evaluated using a receiver operating curves analysis.

RESULTS

Serum MBL levels were significantly higher in patients than in controls. Serum MBL levels were independently associated with WFNS scores and modified Fisher scores. MBL was identified as an independent prognostic predictor for 6-month mortality and unfavorable outcome. Moreover, its predictive value was similar to those of WFNS scores and modified Fisher scores.

CONCLUSIONS

Elevated serum MBL concentrations are associated with injury severity and long-term poor prognosis after aSAH.

Thioredoxin as a marker for severity and prognosis of aneurysmal subarachnoid hemorrhage

OBJECTIVE

Circulating levels of thioredoxin (Trx), a potent anti-oxidant that modulates inflammation, cell growth and apoptosis, are increased in various critical care conditions. The purpose of this study was to establish the relationship between serum Trx levels and prognosis of aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

An enzyme-linked immunosorbent assay measurement of Trx was performed in serum from 132 patients and 132 healthy volunteers. Clinical outcomes included 6-month mortality and unfavorable outcome (Glasgow outcome scale score of 1-3).

RESULTS

The serum Trx levels were significantly higher in patients than in controls (23.4±12.2 ng/mL vs.8.5±4.0 ng/mL, P<0.001) and had close relation to the World Federation of Neurological Surgeons (WFNS) scores (r=0.461, P<0.001) and modified Fisher scores (r=0.459, P<0.001). Trx was an independent predictor for 6-month mortality (Odds ratio, 1.386; 95% confidence interval, 1.015-2.161; P<0.001) and 6-month unfavorable outcome (Odds ratio, 1.297; 95% confidence interval, 1.012-2.002; P<0.001). Based on receiver operating characteristic curve, TRX had similar prognostic value compared with WFNS scores and modified Fisher scores and also significantly improved their prognostic value for 6-month unfavorable outcome, but not for 6-month mortality.

CONCLUSIONS

Elevated plasma Trx levels are correlated with the severity and poor prognosis, substantializing Trx as a potential prognostic predictive biomarker following aSAH.