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Yang C, Zhao Z, Yang B, Wang K, Zhu G, Miao H. Sex Differences in Outcome of Aneurysmal Subarachnoid Hemorrhage and Its Relation to Postoperative Cerebral Ischemia. Neurocrit Care 2024:10.1007/s12028-024-02028-9. [PMID: 38954369 DOI: 10.1007/s12028-024-02028-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/31/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Whether there is a sex difference in the outcome of aneurysmal subarachnoid hemorrhage (aSAH) remains controversial, and clarifying the role of women in postoperative cerebral ischemic events can help us to understand its relationship with poor prognosis. Therefore, the purpose of this study was to elucidate the relationship between the three aspects of sex differences, postoperative cerebral ischemia, and poor prognosis after aSAH. METHODS A total of 472 patients admitted within 72 h after aSAH between January 2018 and December 2022 were included. We systematically analyzed the characteristics of sex differences in aSAH and explored the relationship between delayed cerebral ischemia (DCI), surgery-related cerebral infarction (SRCI), and poor prognosis (modified Rankin Scale > 2). RESULTS Compared with women, men were in worse condition and had more intracerebral hematoma (p = 0.001) on admission, whereas women were older (p < 0.001) and had more multiple aneurysms (p = 0.002). During hospitalization, men were more likely to experience emergency intubation (p = 0.036) and tracheotomy (p = 0.013). Women achieved functional independence at discharge at a similar rate to men (p = 0.394). Among postoperative complications, the incidence of DCI (22% vs. 12%, p = 0.01) and urinary tract infection (p = 0.022) was significantly higher in women. After adjusting for age, multivariable regression analysis showed that hypertension (odds ratio [OR] 2.139, 95% confidence interval [CI] 1.027-4.457), preoperative rerupture (OR 12.240, 95% CI 1.491-100.458), pulmonary infection (OR 2.297, 95% CI 1.070-4.930), external ventricular drainage placement (OR 4.382, 95% CI 1.550-12.390), bacteremia (OR 14.943, 95% CI 1.412-158.117), SRCI (OR 8.588, 95% CI 4.092-18.023), venous thrombosis (OR 5.283, 95% CI 1.859-15.013), higher modified Fisher grades (p = 0.003), and Hunt-Hess grades (p = 0.035) were associated with poor prognosis, whereas DCI (OR 1.394, 95% CI 0.591-3.292) was not an independent risk factor for poor prognosis. The proportion of patients who fully recovered from cerebral ischemia was higher in the DCI group (p < 0.001) compared with the SRCI group, and more patients were discharged with modified Rankin Scale > 2 in the SRCI group (p = 0.005). CONCLUSIONS Women have a higher incidence of DCI, but there is no sex difference in outcomes after aSAH, and poor prognosis is associated with worse admission condition and perioperative complications. SRCI is a strong independent risk factor for poor prognosis, whereas DCI is not.
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Affiliation(s)
- Cheng Yang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Zenan Zhao
- Department of Neurosurgery, Chongqing Western Hospital, Chongqing, 400052, China
| | - Biao Yang
- Department of Neurosurgery, Dazu Hospital of Chongqing Medical University, Chongqing, 402360, China
| | - Kaishan Wang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Hongping Miao
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China.
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Ohgaki F, Tatezuki J, Takemoto Y, Miyazaki K, Mochimatsu Y. Serum C-reactive protein value on day 14 as a possible prognostic factor of aneurysmal subarachnoid hemorrhage. J Int Med Res 2024; 52:3000605241253755. [PMID: 38796856 PMCID: PMC11129573 DOI: 10.1177/03000605241253755] [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: 09/08/2023] [Accepted: 04/20/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE Serum C-reactive protein (CRP), as a reflection of early brain injury at onset, is a prognostic factor in aneurysmal subarachnoid hemorrhage (aSAH). However, in some severe cases, patients exhibit a good prognosis despite their elevated serum CRP level. Therefore, we examined the relationship between serum CRP transitions in the acute phase of aSAH and the prognosis. METHODS We recruited 63 patients with aSAH and retrospectively analyzed the relationships between the serum CRP transitions during the acute phase and the prognosis, patient background, and clinical course. RESULTS Serum CRP values on days 1, 3, and 14 were significantly lower in the good prognosis group than those in the poor prognosis group. Moreover, serum CRP values on days 1 and 14 significantly affected the prognosis in the multiple regression analysis. CONCLUSIONS A low serum CRP value on day 14, in addition to that on day 1 as reported previously, is associated with a good prognosis of aSAH. Furthermore, a good prognosis of aSAH is determined not only by absence of early brain injury at onset but also by appropriate management to obtain a low serum CRP value on day 14.
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Affiliation(s)
- Fukutaro Ohgaki
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Junya Tatezuki
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Yasunori Takemoto
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Kazuki Miyazaki
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Yasuhiko Mochimatsu
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Florez WA, Martinez-Perez R, Deora H, Joaquim AF, García-Ballestas E, Quiñones-Ossa GA, Rivas-Palacios C, Agrawal A, Serrato SA, Jabbour P, Moscote-Salazar LR. An update of predictors of cerebral infarction after aneurysmal subarachnoid hemorrhage: systematic review and meta-analysis. J Neurosurg Sci 2023; 67:1-9. [PMID: 36112119 DOI: 10.23736/s0390-5616.22.05445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Evidence about predictors of poor outcomes such as cerebral infarction (CI) after aneurysmal subarachnoid hemorrhage (aSAH) has not been fully elucidated. EVIDENCE ACQUISITION We performed a systematic review and meta-analysis on studies with adults with aSAH considering RCT and non-RCT, prospective, and retrospective cohort studies describing clinical, imaging as well as angiographic studies in patients with aSAH. EVIDENCE SYNTHESIS After reviewing the complete text, 11 studies were considered eligible, out of which four were ruled out. Degree of clinical severity was the most predictive factor with a higher degree at the presentation on different severity scales being associated with a statistically significant increasing the risk of suffering a CI following aSAH (OR 2.49 [95% CI 1.38-4.49] P=0.0003). Aneurysm size increased the risk of CI (OR 1.49 [95% CI 1.20-1.85] P=0.0003; I2=4%). In six studies analyzed, it was found that an important factor for the subsequent development of CI is vasospasm (OR 7.62 [2.19, 26.54], P=0.0001). CONCLUSIONS The development of vasospasm is a risk factor for CI development after aSAH. In our review, three factors were associated with an increased risk of CI: clinical severity at presentation, vasospasm, and aneurysm size. The major limitation of this meta-analysis is that included studies were conducted retrospectively or were post hoc analyses of a prospective trial.
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Affiliation(s)
- William A Florez
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Faculty of Medicine, Universidad Surcolombiana, Neiva, Colombia
| | - Rafael Martinez-Perez
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.,Division of Neurosurgery, Institute of Neurosciences, Austral University of Chile, Valdivia, Chile
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Andrei F Joaquim
- Department of Neurosurgery. University of Campinas (UNICAMP), São Paulo, Brazil
| | - Ezequiel García-Ballestas
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Gabriel A Quiñones-Ossa
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia - .,Faculty of Medicine, El Bosque University, Bogotá, Colombia
| | - Claudio Rivas-Palacios
- Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | | | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Luis R Moscote-Salazar
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Faculty of Medicine, Universidad Surcolombiana, Neiva, Colombia
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Shi M, Zhang TB, Li XF, Zhang ZY, Li ZJ, Wang XL, Zhao WY. The prognostic value of hyperglycemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:3717-3728. [PMID: 36169785 DOI: 10.1007/s10143-022-01870-9] [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: 06/21/2022] [Revised: 08/25/2022] [Accepted: 09/16/2022] [Indexed: 11/27/2022]
Abstract
Recent studies have demonstrated that hyperglycemia may result in a poor prognosis following aneurysmal subarachnoid hemorrhage (aSAH). However, the association between hyperglycemia and the clinical outcome of aSAH has not been clearly established thus far. Therefore, we performed a systematic review and meta-analysis to investigate the association between hyperglycemia and the development of aSAH. We completed a literature search in four databases (PubMed, EMBASE, Cochrane Library, and Web of Science) up to November 1, 2021, including all eligible studies investigating the prognostic value of hyperglycemia in patients with aSAH. We performed a quality assessment of included studies using the Newcastle-Ottawa Quality Assessment Scale. The pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated to assess the association of hyperglycemia in aneurysmal subarachnoid hemorrhage. A total of 35 studies with 11,519 patients were finally included in the meta-analysis. Nineteen studies reported the association between hyperglycemia and poor outcome, 12 studies reported the association between hyperglycemia and all-cause mortality, 7 studies reported the association between hyperglycemia and cerebral vasospasm, and 9 studies reported the association between hyperglycemia and cerebral infarction. The pooled data of these studies suggested that hyperglycemia was significantly associated with poor functional outcomes (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.17-1.42; P < 0.00001; I2 = 83%), all-cause mortality (OR, 1.02; 95% CI, 1.01-1.04; P = 0.0006; I2 = 89%), cerebral vasospasm (OR, 1.02; 95% CI, 1.01-1.02; P = 0.0002; I2 = 35%), and cerebral infarction (OR, 1.16; 95% CI, 1.09-1.23; P < 0.00001; I2 = 10%) in aSAH patients. These findings suggested that assessing for hyperglycemia at admission may help clinicians to identify critically ill patients and complete patient stratification early, which may achieve better management and improve the prognosis of patients with aSAH.
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Affiliation(s)
- Min Shi
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ting-Bao Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiao-Feng Li
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zong-Yong Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ze-Jin Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xue-Lou Wang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wen-Yuan Zhao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China.
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Winberg J, Holm I, Cederberg D, Rundgren M, Kronvall E, Marklund N. Cerebral Microdialysis-Based Interventions Targeting Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2022; 37:255-266. [PMID: 35488171 PMCID: PMC9283139 DOI: 10.1007/s12028-022-01492-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/14/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI), a complication of subarachnoid hemorrhage (SAH), is linked to cerebral vasospasm and associated with poor long-term outcome. We implemented a structured cerebral microdialysis (CMD) based protocol using the lactate/pyruvate ratio (LPR) as an indicator of the cerebral energy metabolic status in the neurocritical care decision making, using an LPR ≥ 30 as a cutoff suggesting an energy metabolic disturbance. We hypothesized that CMD monitoring could contribute to active, protocol-driven therapeutic interventions that may lead to the improved management of patients with SAH. METHODS Between 2018 and 2020, 49 invasively monitored patients with SAH, median Glasgow Coma Scale 11 (range 3-15), and World Federation of Neurosurgical Societies scale 4 (range 1-5) on admission receiving CMD were included. We defined a major CMD event as an LPR ≥ 40 for ≥ 2 h and a minor CMD event as an LPR ≥ 30 for ≥ 2 h. RESULTS We analyzed 7,223 CMD samples over a median of 6 days (5-8). Eight patients had no CMD events. In 41 patients, 113 minor events were recorded, and in 23 patients 42 major events were recorded. Our local protocols were adhered to in 40 major (95%) and 98 minor events (87%), with an active intervention in 32 (76%) and 71 (63%), respectively. Normalization of energy metabolic status (defined as four consecutive samples with LPR < 30 for minor and LPR < 40 for major events) was seen after 69% of major and 59% of minor events. The incidence of DCI-related infarcts was 10% (five patients), with only two observed in a CMD-monitored brain region. CONCLUSIONS Active interventions were initiated in a majority of LPR events based on CMD monitoring. A low DCI incidence was observed, which may be associated with the active interventions. The potential aid of CMD in the clinical decision-making targeting DCI needs confirmation in additional SAH studies.
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Affiliation(s)
- Jakob Winberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Isabella Holm
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - David Cederberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Malin Rundgren
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Erik Kronvall
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Neurosurgery, EA-blocket plan 4, Entrégatan 7, 222 42, Lund, Sweden.
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Magnetic Resonance Imaging in Aneurysmal Subarachnoid Hemorrhage: Current Evidence and Future Directions. Neurocrit Care 2019; 29:241-252. [PMID: 29633155 DOI: 10.1007/s12028-018-0534-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with an unacceptably high mortality and chronic disability in survivors, underscoring a need to validate new approaches for treatment and prognosis. The use of advanced imaging, magnetic resonance imaging (MRI) in particular, could help address this gap given its versatile capacity to quantitatively evaluate and map changes in brain anatomy, physiology and functional activation. Yet there is uncertainty about the real value of brain MRI in the clinical setting of aSAH. METHODS In this review, we discuss current and emerging MRI research in aSAH. PubMed was searched from inception to June 2017, and additional studies were then chosen on the basis of relevance to the topics covered in this review. RESULTS Available studies suggest that brain MRI is a feasible, safe, and valuable testing modality. MRI detects brain abnormalities associated with neurologic examination, outcomes, and aneurysm treatment and thus has the potential to increase knowledge of aSAH pathophysiology as well as to guide management and outcome prediction. Newer pulse sequences have the potential to reveal structural and physiological changes that could also improve management of aSAH. CONCLUSION Research is needed to confirm the value of MRI-based biomarkers in clinical practice and as endpoints in clinical trials, with the goal of improving outcome for patients with aSAH.
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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: 13] [Impact Index Per Article: 2.6] [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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Fragata I, Canhão P. Imaging predictors of outcome in acute spontaneous subarachnoid hemorrhage: a review of the literature. Acta Radiol 2019; 60:247-259. [PMID: 29792042 DOI: 10.1177/0284185118778877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Spontaneous subarachnoid hemorrhage (SAH) accounts for about 5% of strokes, but has a very high morbidity and mortality. Many survivors are left with important cognitive impairment and are severely incapacitated. Prediction of complications such as vasospasm and delayed cerebral ischemia, and of clinical outcome after SAH, is challenging. Imaging studies are essential in the initial evaluation of SAH patients and are increasingly relevant in assessing for complications and prognosis. In this article, we reviewed the role of imaging studies in evaluating early brain injury and predicting complications as well as clinical and neuropsychological prognosis after acute SAH.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department, Hospital São José, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Patrícia Canhão
- Department of Neurosciences and Mental Health, Department of Neurology, Hospital de Santa Maria, CHLN, Lisbon, Portugal
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Kim JW, Seung WB. Delayed Branching Artery Occlusion Caused by Clip Rotation after Intracranial Aneurysm Clippings. Case Rep Neurol 2018; 10:159-164. [PMID: 30057543 PMCID: PMC6062732 DOI: 10.1159/000490375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/16/2018] [Indexed: 12/31/2022] Open
Abstract
Clip rotation after clipping is a major cause of delayed cerebral ischemia and may occur after any of several intraoperative monitoring techniques. We experienced 3 cases of clip rotation in 3 patients after clipping between March 2011 and December 2013. One of these patients has permanent motor weakness of the left upper extremity because of delayed occlusion of the right M1 lenticulostriate artery. The other two developed delayed occlusion of the frontopolar artery or of the A1 perforating artery, but did not have any neurologic deficits. Clinicians need to exercise great care not to compromise distal blood flow after clipping intracranial aneurysms. We present 3 cases in which clip rotation occurred after aneurysm clipping and progressively compromised blood flow of a nearby branching artery.
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Affiliation(s)
- Jin Wook Kim
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Republic of Korea
| | - Won-Bae Seung
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Republic of Korea
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Gonçalves B, Turon R, Mendes A, Melo N, Lacerda P, Brasil P, Bozza FA, Kurtz P, Righy C. Effect of Early Brain Infarction After Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:e292-e298. [PMID: 29660554 DOI: 10.1016/j.wneu.2018.04.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is an acute cerebrovascular event that leads to devastating consequences. Early brain infarction (EBI) develops very early, within the first 72 hours after bleeding, and may have a significant impact on long-term outcomes. The incidence and impact of EBI in the prognosis of aSAH remain uncertain. We performed a systematic review and meta-analysis to evaluate the incidence of EBI in patients with aSAH and determine its effect on mortality and functional outcomes. METHODS We performed a systematic review and meta-analysis. Inclusion criteria were 1) studies that evaluated aSAH within 72 hours after bleeding; 2) performed a brain imaging study up to 72 hours of hemorrhage; 3) used computed tomography or magnetic resonance imaging; and 4) included a description of the findings of the brain imaging study (whether or not an infarct was present). RESULTS Ten studies that met the criteria were included. The incidence of EBI was 17%. The risk ratio for 3-month mortality was 2.18 (95% confidence interval 1.48-3.30). The overall risk ratio for poor outcome was 2.26 (95% confidence interval 1.75-2.93). CONCLUSIONS EBI plays an important role in the outcome of patients with aSAH. Its significant impact could represent a new therapeutic frontier for improving outcomes of these patients.
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Affiliation(s)
- Bruno Gonçalves
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Oswaldo Cruz Foundation, National Institute of Infectology, Rio de Janeiro, Brazil; Copa Star Hospital, Intensive Care Unit, Rio de Janeiro, Brazil.
| | - Ricardo Turon
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Niterói Hospital Complex, Neurocritical Care Unit, Niterói, Brazil
| | - Antenor Mendes
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Copa Star Hospital, Intensive Care Unit, Rio de Janeiro, Brazil
| | - Nivea Melo
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Copa Star Hospital, Intensive Care Unit, Rio de Janeiro, Brazil
| | - Paula Lacerda
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil
| | - Pedro Brasil
- Oswaldo Cruz Foundation, National Institute of Infectology, Rio de Janeiro, Brazil
| | - Fernando Augusto Bozza
- Oswaldo Cruz Foundation, National Institute of Infectology, Rio de Janeiro, Brazil; D'Or Institute for Research and Eduaction, Rio de Janeiro, Brazil
| | - Pedro Kurtz
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Copa Star Hospital, Intensive Care Unit, Rio de Janeiro, Brazil
| | - Cassia Righy
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Oswaldo Cruz Foundation, National Institute of Infectology, Rio de Janeiro, Brazil
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Association of Perforator Infarction with Clinical Courses and Outcomes Following Surgical Clipping of Ruptured Anterior Communicating Artery Aneurysms. World Neurosurg 2017; 107:724-731. [DOI: 10.1016/j.wneu.2017.08.086] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 11/23/2022]
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Rinaldo L, Hughes JD, Rabinstein AA, Lanzino G. Effect of body mass index on outcome after aneurysmal subarachnoid hemorrhage treated with clipping versus coiling. J Neurosurg 2017; 129:658-669. [PMID: 29027862 DOI: 10.3171/2017.4.jns17557] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It has been suggested that increased body mass index (BMI) may confer a protective effect on patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). Whether the modality of aneurysm occlusion influences the effect of BMI on patient outcomes is not well understood. The authors aimed to compare the effect of BMI on outcomes for patients with aSAH treated with surgical clipping versus endovascular coiling. METHODS The authors retrospectively reviewed the outcomes for patients admitted to their institution for the management of aSAH treated with either clipping or coiling. BMI at the time of admission was recorded and used to assign patients to a group according to low or high BMI. Cutoff values for BMI were determined by classification and regression tree analysis. Predictors of poor functional outcome (defined as modified Rankin Scale score > 2 measured ≥ 90 days after the ictus) and posttreatment cerebral hypodensities detected during admission were then determined separately for patients treated with clipping or coiling using stepwise multivariate logistic regression analysis. RESULTS Of the 469 patients admitted to the authors' institution with aSAH who met the study's inclusion criteria, 144 were treated with clipping and 325 were treated with coiling. In the clipping group, the frequency of poor functional outcome was higher in patients with BMI ≥ 32.3 kg/m2 (47.6% vs 19.0%; p = 0.007). In contrast, in the coiling group, patients with BMI ≥ 32.3 kg/m2 had a lower frequency of poor functional outcome at ≥ 90 days (5.8% vs 30.9%; p < 0.001). On multivariate analysis, high BMI was independently associated with an increased (OR 3.92, 95% CI 1.20-13.41; p = 0.024) and decreased (OR 0.13, 95% CI 0.03-0.40; p < 0.001) likelihood of poor functional outcome for patients treated with clipping and coiling, respectively. For patients in the surgical group, BMI ≥ 28.4 kg/m2 was independently associated with incidence of cerebral hypodensities during admission (OR 2.44, 95% CI 1.16-5.25; p = 0.018) on multivariate analysis. For patients treated with coiling, BMI ≥ 33.2 kg/m2 was independently associated with reduced odds of hypodensities (OR 0.45, 95% CI 0.21-0.89; p = 0.021). CONCLUSIONS The results of this study suggest that BMI may differentially affect functional outcomes after aSAH, depending on treatment modality. These findings may aid in treatment selection for patients with aSAH.
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Affiliation(s)
| | | | | | - Giuseppe Lanzino
- Departments of1Neurosurgery.,3Neurointerventional Radiology, Mayo Clinic, Rochester, Minnesota
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Ayling OG, Ibrahim GM, Alotaibi NM, Gooderham PA, Macdonald RL. Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage. Stroke 2016; 47:2945-2951. [DOI: 10.1161/strokeaha.116.014794] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/08/2016] [Accepted: 09/21/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Cerebral infarction after aneurysmal subarachnoid hemorrhage is a significant cause of substantial morbidity and mortality. Because early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage may be mediated by different processes, we evaluated whether aneurysm-securing methods contributed to infarcts and whether long-term outcomes differ between early and delayed infarcts.
Methods—
A post hoc analysis of the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) was performed. Using multivariate logistic regression analysis and propensity matching, independent clinical risk factors associated with infarctions were identified, and the contribution of cerebral infarcts to long-term outcomes was evaluated.
Results—
Within the cohort of 413 subjects, early infarcts were present in 76 subjects (18%), whereas delayed infarcts occurred in 79 subjects (19%), and 36 subjects (9%) had new infarctions that were present on both early and delayed imaging. Propensity score matching revealed a significantly higher proportion of early infarcts after clipping (odds ratio, 4.62; 95% confidence interval, 1.99–11.57;
P
=0.00012). Multivariate logistic regressions identified clipping as an independent risk factor for early cerebral infarction (odds ratio, 0.26; 95% confidence interval, 0.15–0.48;
P
<0.001), and angiographic vasospasm was an independent risk factor for delayed cerebral infarction (odds ratio, 1.79; 95% confidence interval, 1.03–3.13;
P
=0.039). Early infarcts were a significant independent risk factor for poor long-term outcomes at 3 months (odds ratio, 2.34; 95% confidence interval, 1.18–4.67;
P
=0.015).
Conclusions—
Clipping is an independent risk factor for the development of early cerebral infarcts, whereas delayed cerebral infarcts are associated with angiographic vasospasm. Early cerebral infarcts are stronger predictors of worse outcome than delayed infarction.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00111085.
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Affiliation(s)
- Oliver G.S. Ayling
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - George M. Ibrahim
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - Naif M. Alotaibi
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - Peter A. Gooderham
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - R. Loch Macdonald
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
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15
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Wong GKC, Leung JHY, Yu JWL, Lam SW, Chan EKY, Poon WS, Abrigo J, Siu DYW. Early Cerebral Infarction after Aneurysmal Subarachnoid Hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 121:157-159. [PMID: 26463941 DOI: 10.1007/978-3-319-18497-5_28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a serious disease with high case fatality and morbidity. Early cerebral infarction has been suggested as a risk factor for poor outcome. We aimed to assess the pattern of early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage. We prospectively enrolled consecutive aneurysmal subarachnoid hemorrhage (SAH) patients presenting to an academic neurosurgical referral center (Prince of Wales Hospital, the Chinese University of Hong Kong) in Hong Kong. Cerebral infarction occurred in 24 (48 %) patients, in which 14 (28 %) had early cerebral infarction and 14 (28 %) had delayed cerebral infarction. Early anterior cerebral infarction occurred in a similar proportion of anterior and posterior circulation aneurysms (24 % vs. 21 %), whereas posterior circulation aneurysm patients had a higher proportion of early posterior cerebral infarction compared with anterior circulation aneurysm patients (18 % vs. 2 %). In conclusion, early cerebral infarction was common and different from delayed cerebral infarction.
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Affiliation(s)
- George Kwok Chu Wong
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
- Department of Surgery, Prince of Wales Hospital, 4/F Clinical Science Building, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong, SAR, China.
| | - Joyce Hoi Ying Leung
- Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Janice Wong Li Yu
- Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Sandy Wai Lam
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Emily Kit Ying Chan
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Jill Abrigo
- Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Deyond Yun Woon Siu
- Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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16
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Early identification of individuals at high risk for cerebral infarction after aneurysmal subarachnoid hemorrhage: the BEHAVIOR score. J Cereb Blood Flow Metab 2015; 35:1587-92. [PMID: 25920954 PMCID: PMC4640318 DOI: 10.1038/jcbfm.2015.81] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/12/2015] [Accepted: 03/25/2015] [Indexed: 11/09/2022]
Abstract
Cerebral infarction (CI) is a crucial complication of aneurysmal subarachnoid hemorrhage (SAH) associated with poor clinical outcome. We aimed at developing an early risk score for CI based on clinical characteristics available at the onset of SAH. Out of a database containing 632 consecutive patients with SAH admitted to our institution from January 2005 to December 2012, computed tomography (CT) scans up to day 42 after ictus were evaluated for CIs. Different parameters from admission up to aneurysm treatment were collected with subsequent construction of a risk score. Seven clinical characteristics were independently associated with CI and included in the Risk score (BEHAVIOR Score, 0 to 11 points): Blood on CT scan according to Fisher grade ⩾3 (1 point), Elderly patients (age ⩾55 years, 1 point), Hunt&Hess grade ⩾4 (1 point), Acute hydrocephalus requiring external liquor drainage (1 point), Vasospasm on initial angiogram (3 points), Intracranial pressure elevation >20 mm Hg (3 points), and treatment of multiple aneurysms ('Overtreatment', 1 point). The BEHAVIOR score showed high diagnostic accuracy with respect to the absolute risk for CI (area under curve=0.806, P<0.0001) and prediction of poor clinical outcome at discharge (P<0.0001) and after 6 months (P=0.0002). Further validation in other SAH cohorts is recommended.
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Abstract
INTRODUCTION Insufficient cerebral perfusion pressure (CPP) after aneurysmal subarachnoid hemorrhage can impair cerebral blood flow. We examined the temporal profiles of CPP change and tested whether these profiles were associated with delayed cerebral ischemia (DCI). METHOD CPP values were retrospectively reviewed for 238 subjects. Intracranial pressure and mean arterial pressure values were obtained every 2 hours for 14 days. Induced hypertension was utilized to prevent vasospasm. The linear and quadratic CPP changes over time were tested using growth curve analysis. Multivariable logistic regression was utilized to examine the association between DCI and percentages of CPP values of >110, >100, <70, and <60 mm Hg. DCI was defined as neurological deterioration because of impaired cerebral blood flow. RESULTS Between-subject differences accounted for 39% of variation in CPP values. There was a significant linear increase in CPP values over time (β = 0.06, SE = 0.006, p < .001). The covariance (-0.52, SE = 0.09, p < .001) between initial CPP and linear parameter was negative, indicating that subjects with high CPP on admission had a slower rate of increase whereas those with low CPP had a faster rate of increase. For every 10% increase in the proportion of CPP of >100 or >110 mm Hg, the odds of DCI increased by 1.21 and 1.43, respectively (p < .05). CONCLUSIONS The longer the time patients spent with high CPP, the greater the odds for DCI. When used prophylactically, induced hypertension contributes to higher CPP values. On the basis of the CPP trends and correlations observed, induced hypertension may not confer expected benefits in patients with aneurysmal subarachnoid hemorrhage.
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18
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Jabbarli R, Reinhard M, Niesen WD, Roelz R, Shah M, Kaier K, Hippchen B, Taschner C, Van Velthoven V. Predictors and impact of early cerebral infarction after aneurysmal subarachnoid hemorrhage. Eur J Neurol 2015; 22:941-7. [DOI: 10.1111/ene.12686] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 12/29/2014] [Indexed: 11/30/2022]
Affiliation(s)
- R. Jabbarli
- Department of Neurosurgery; University Hospital of Freiburg; Freiburg Germany
- Department of Neurosurgery; University Hospital of Essen; Essen Germany
| | - M. Reinhard
- Department of Neurology; University Hospital of Freiburg; Freiburg Germany
| | - W.-D. Niesen
- Department of Neurology; University Hospital of Freiburg; Freiburg Germany
| | - R. Roelz
- Department of Neurosurgery; University Hospital of Freiburg; Freiburg Germany
| | - M. Shah
- Department of Neurosurgery; University Hospital of Freiburg; Freiburg Germany
| | - K. Kaier
- Institute for Medical Biometry and Medical Informatics; University Hospital of Freiburg; Freiburg Germany
| | - B. Hippchen
- Department of Neurosurgery; University Hospital of Freiburg; Freiburg Germany
| | - C. Taschner
- Department of Neuroradiology; University Hospital of Freiburg; Freiburg Germany
| | - V. Van Velthoven
- Department of Neurosurgery; University Hospital of Freiburg; Freiburg Germany
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19
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Frontera JA, Ahmed W, Zach V, Jovine M, Tanenbaum L, Sehba F, Patel A, Bederson JB, Gordon E. Acute ischaemia after subarachnoid haemorrhage, relationship with early brain injury and impact on outcome: a prospective quantitative MRI study. J Neurol Neurosurg Psychiatry 2015; 86:71-8. [PMID: 24715224 DOI: 10.1136/jnnp-2013-307313] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine if ischaemia is a mechanism of early brain injury at the time of aneurysm rupture in subarachnoid haemorrhage (SAH) and if early MRI ischaemia correlates with admission clinical status and functional outcome. METHODS In a prospective, hypothesis-driven study patients with SAH underwent MRI within 0-3 days of ictus (prior to vasospasm) and a repeat MRI (median 7 days). The volume and number of diffusion weighted imaging (DWI) positive/apparent diffusion coefficient (ADC) dark lesions on acute MRI were quantitatively assessed. The association of early ischaemia, admission clinical status, risk factors and 3-month outcome were analysed. RESULTS In 61 patients with SAH, 131 MRI were performed. Early ischaemia occurred in 40 (66%) with a mean DWI/ADC volume 8.6 mL (0-198 mL) and lesion number 4.3 (0-25). The presence of any early DWI/ADC lesion and increasing lesion volume were associated with worse Hunt-Hess grade, Glasgow Coma Scale score and Acute Physiology and Chronic Health Evaluation II physiological subscores (all p<0.05). Early DWI/ADC lesions significantly predicted increased number and volume of infarcts on follow-up MRI (p<0.005). At 3 months, early DWI/ADC lesion volume was significantly associated with higher rates of death (21% vs. 3%, p=0.031), death/severe disability (modified Rankin Scale 4-6; 53% vs. 15%, p=0.003) and worse Barthel Index (70 vs. 100, p=0.004). After adjusting for age, Hunt-Hess grade and aneurysm size, early infarct volume correlated with death/severe disability (adjusted OR 1.7, 95% CI 1.0 to 3.2, p=0.066). CONCLUSIONS Early ischaemia is related to poor acute neurological status after SAH and predicts future ischaemia and worse functional outcomes. Treatments addressing acute ischaemia should be evaluated for their effect on outcome.
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Affiliation(s)
- Jennifer A Frontera
- Cleveland Clinic, Cerebrovascular Center of the Neurological Institute, Cleveland, Ohio, USA
| | - Wamda Ahmed
- Neuroscience Intensive Care Unit, Departments of Neurosurgery and Neurology, Mount Sinai School of Medicine, New York, New York, USA
| | - Victor Zach
- Neuroscience Intensive Care Unit, Departments of Neurosurgery and Neurology, Mount Sinai School of Medicine, New York, New York, USA
| | - Maximo Jovine
- Neuroscience Intensive Care Unit, Departments of Neurosurgery and Neurology, Mount Sinai School of Medicine, New York, New York, USA
| | - Lawrence Tanenbaum
- Neuroradiology Department, Mount Sinai School of Medicine, New York, New York, USA
| | - Fatima Sehba
- Neuroscience Intensive Care Unit, Departments of Neurosurgery and Neurology, Mount Sinai School of Medicine, New York, New York, USA
| | - Aman Patel
- Neuroscience Intensive Care Unit, Departments of Neurosurgery and Neurology, Mount Sinai School of Medicine, New York, New York, USA
| | - Joshua B Bederson
- Neuroscience Intensive Care Unit, Departments of Neurosurgery and Neurology, Mount Sinai School of Medicine, New York, New York, USA
| | - Errol Gordon
- Neuroscience Intensive Care Unit, Departments of Neurosurgery and Neurology, Mount Sinai School of Medicine, New York, New York, USA
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21
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Kumar A, Brown R, Dhar R, Sampson T, Derdeyn CP, Moran CJ, Diringer MN. Early vs Delayed Cerebral Infarction After Aneurysm Repair After Subarachnoid Hemorrhage. Neurosurgery 2013; 73:617-23; discussion 623. [DOI: 10.1227/neu.0000000000000057] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral infarction is a major contributor to poor outcome after subarachnoid hemorrhage (SAH). Although usually considered a complication of delayed cerebral ischemia, infarcts may also occur early, in relation to initial brain injury or aneurysm-securing procedures.
OBJECTIVE:
We analyzed the relative frequency and volume of early vs delayed infarcts after SAH and their relationship to hospital outcome.
METHODS:
Retrospective review of consecutive patients admitted with aneurysmal SAH over 4 years who had follow-up brain imaging 7 days or later after admission. Imaging 24 to 48-hours after aneurysm-securing procedures was reviewed to classify infarcts seen on final imaging as early or delayed. Infarct volumes were measured by perimeter tracing and infarct burden calculated for each patient.
RESULTS:
Of 250 eligible patients, 205 had follow-up imaging; infarcts were present in 61 patients. Of these, 29 had early infarcts, 16 had delayed infarcts, and 5 had both early and delayed infarcts. Eleven patients with infarcts did not undergo postprocedure computed tomography; these were presumptively classified as having late infarcts. Early and delayed infarcts contributed equally to infarct burden. Early infarcts were associated with aneurysm clipping (odds ratio: 4.2, 95% confidence interval: 1.8-9.5 compared with coiling), whereas delayed infarcts were almost always seen in association with angiographic vasospasm (odds ratio: 3.3, 95% confidence interval: 1.5-7.3). Patients with early as well as late infarcts, especially those with infarct burden more than 30 cm3 had worse hospital discharge disposition.
CONCLUSION:
Early infarction occurs frequently after SAH and contributes as much as delayed cerebral ischemia to infarct burden and hospital outcome. Efforts to better understand and modify contributors to early infarction appear warranted.
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Affiliation(s)
- Abhay Kumar
- Departments of Neurology Washington University School of Medicine, St. Louis, Missouri
| | - Robert Brown
- Departments of Neurology Washington University School of Medicine, St. Louis, Missouri
| | - Rajat Dhar
- Departments of Neurology Washington University School of Medicine, St. Louis, Missouri
| | - Tomoko Sampson
- Departments of Neurology Washington University School of Medicine, St. Louis, Missouri
| | - Colin P. Derdeyn
- Departments of Radiology and Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J. Moran
- Departments of Radiology and Washington University School of Medicine, St. Louis, Missouri
| | - Michael N. Diringer
- Departments of Neurology Washington University School of Medicine, St. Louis, Missouri
- Departments of Radiology and Washington University School of Medicine, St. Louis, Missouri
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Malmivaara K, Juvela S, Hernesniemi J, Lappalainen J, Siironen J. Health-related quality of life and cost-effectiveness of treatment in subarachnoid haemorrhage. Eur J Neurol 2012; 19:1455-61. [DOI: 10.1111/j.1468-1331.2012.03744.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 03/22/2012] [Indexed: 11/28/2022]
Affiliation(s)
- K. Malmivaara
- Children's Hospital; Helsinki University Central Hospital; Helsinki Finland
| | - S. Juvela
- Department of Clinical Neurosciences; University of Helsinki; Helsinki Finland
| | - J. Hernesniemi
- Department of Neurosurgery; Helsinki University Central Hospital; Helsinki Finland
| | - J. Lappalainen
- Department of Neurosurgery; Helsinki University Central Hospital; Helsinki Finland
| | - J. Siironen
- Department of Neurosurgery; Helsinki University Central Hospital; Helsinki Finland
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23
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Juvela S. C-reactive protein after aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 2012. [DOI: 10.1007/s00701-012-1344-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Juvela S, Kuhmonen J, Siironen J. C-reactive protein as predictor for poor outcome after aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 2012; 154:397-404. [PMID: 22134501 DOI: 10.1007/s00701-011-1243-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 11/21/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (SAH) is a severe disease with high case-fatality and morbidity rates. After SAH, the value of C-reactive protein (CRP)--an acute phase sensitive inflammatory marker--as a prognostic factor has been poorly studied, with conflicting results. In this prospective study, we tested whether increased CRP levels increase independently the risk for cerebral infarct and poor outcome. METHODS Previous diseases as well as clinical, laboratory and radiological variables were recorded for 178 patients with SAH admitted within 48 h and with aneurysms occluded within 60 h after bleeding. Plasma CRP was measured, as well as computed tomography (CT) scans routinely obtained on admission, in the morning after aneurysm occlusion, and at discharge during second week after SAH. Factors predicting occurrence of cerebral infarct and poor outcome at 3 months after SAH were tested with multiple logistic regression. RESULTS CRP levels increased significantly (p < 0.001) between hospital admission (mean ± SD, 11.4 ± 21.3 mg/l) and the postoperative morning (27.0 ± 31.0 mg/l) and then decreased (p < 0.001) during the the second week (19.8 ± 25.0 mg/l). Admission (18.0 ± 35.7 vs 8.5 ± 8.4 mg/l) and postoperative (41.0 ± 40.2 vs 21.1 ± 24.1 mg/l) CRP levels were higher (p < 0.001) in those with a poor outcome than in those with a favourable outcome, but CRP values did not predict delayed cerebral ischaemia or cerebral infarction. CRP levels did not independently predict outcome, since these correlated with admission clinical grade and occurrence of intraventricular haemorrhage. Higher increase in CRP level between admission and postoperative morning, however, independently predicted poor outcome (p = 0.004). Part of this increased risk was likely due to an appearance of early postoperative cerebral infarction. CONCLUSIONS CRP levels correlate with outcome but do not seem to predict delayed cerebral ischaemia or infarction after SAH.
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Affiliation(s)
- Seppo Juvela
- Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland.
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Hantson P. Physiopathologie des lésions cérébrales précoces et retardées dans l’hémorragie sous-arachnoïdienne : avancées récentes. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0418-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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