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Santana D, Mosteiro A, Llull L, Massons M, Zattera L, Pujol-Fontrodona G, Werner M, Torné R, Amaro S, Chamorro A. Stroke Unit as an alternative to Intensive Care Unit for initial hospital admission of low-grade non-aneurysmal subarachnoid haemorrhage: A safety and cost-minimisation analysis. Eur Stroke J 2024; 9:180-188. [PMID: 37746931 PMCID: PMC10916811 DOI: 10.1177/23969873231202361] [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: 07/16/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023] Open
Abstract
INTRODUCTION Stroke Units (SU) have been suggested as an alternative to Intensive Care units (ICU) for initial admission of low-grade non-aneurysmal spontaneous subarachnoid haemorrhage (naSAH). We hypothesised that the incidence of in-hospital complications and long-term clinical outcomes in low-grade naSAH patients would be comparable in both settings, and that a cost-minimisation analysis would favour the use of SU. PATIENTS AND METHODS Retrospective, single-centre study at a third-level stroke-referral hospital, including low-grade spontaneous naSAH patients with WFNS 1-2. Primary outcomes were death and functional status at 3 months. Secondary outcomes were incidence of in-hospital major neurological and systemic complications. Additionally, a cost-minimisation analysis was conducted to estimate the average cost savings that could be achieved with the most efficient approach. RESULTS Out of 96 naSAH patients, 30 (31%) were initially admitted to ICU and 66 (69%) to SU. Both groups had similar demographic and radiological features except for a higher proportion of WFNS 2 in ICU subgroup. There were no statistically significant differences between ICU and SU-managed subgroups in death rate (2 (7%) and 1 (2%), respectively), functional outcome at 90 days (28 (93%) and 61 (92%) modified Rankin Scale 0-2) or neurological and systemic in-hospital complications. Cost-minimisation analysis demonstrated significant monetary savings favouring the SU strategy. DISCUSSION AND CONCLUSION Initial admission to the SU appears to be a safe and cost-effective alternative to the ICU for low-grade naSAH patients, with comparable clinical outcomes and a reduction of hospitalisation-related costs. Prospective multicenter randomised studies are encouraged to further evaluate this approach.
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Affiliation(s)
- Daniel Santana
- Institute of Neuroscience, Comprehensive Stroke Center, Hospital Clínic of Barcelona, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
| | - Alejandra Mosteiro
- Universitat de Barcelona, Barcelona, Spain
- Institute of Neuroscience, Neurosurgery Department, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Laura Llull
- Institute of Neuroscience, Comprehensive Stroke Center, Hospital Clínic of Barcelona, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
| | - Miquel Massons
- Institute of Neuroscience, Comprehensive Stroke Center, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Luigi Zattera
- Universitat de Barcelona, Barcelona, Spain
- Anesthesiology Department, Neurocritical Care Division, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Gabriel Pujol-Fontrodona
- Universitat de Barcelona, Barcelona, Spain
- Anesthesiology Department, Neurocritical Care Division, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Mariano Werner
- Institute of Diagnostic Imaging, Neurointerventional Radiology Department, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Ramón Torné
- Universitat de Barcelona, Barcelona, Spain
- Institute of Neuroscience, Neurosurgery Department, Hospital Clínic of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Sergio Amaro
- Institute of Neuroscience, Comprehensive Stroke Center, Hospital Clínic of Barcelona, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Angel Chamorro
- Institute of Neuroscience, Comprehensive Stroke Center, Hospital Clínic of Barcelona, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
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Ragaglini C, Foschi M, De Santis F, Molliconi AL, Conversi F, Colangeli E, Ornello R, Sacco S. Epidemiology and treatment of atraumatic subarachnoid hemorrhage over 10 years in a population-based registry. Eur Stroke J 2024; 9:200-208. [PMID: 37665157 PMCID: PMC10916829 DOI: 10.1177/23969873231198324] [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: 06/05/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023] Open
Abstract
INTRODUCTION Incidence of atraumatic subarachnoid hemorrhage (SAH) is decreasing over time and its treatment is changing. We reported epidemiologic data on aneurysmal (a-) and non-aneurysmal (na-) SAH over 10 years. PATIENTS AND METHODS Our prospective population-based registry included patients with first-ever SAH occurring from January 2011 to December 2020. Clinical and neuroimaging records were screened to evaluate the presence and location of intracranial aneurysms, to identify naSAH subtypes and to retrieve information on surgical treatments. Incidence rates were standardized to the 2011 Italian and European population. We also estimated 30-day and 1-year case-fatality rates after SAH. Multivariate hazard ratios for 30-days and 1-year fatality were estimated with Cox regression analysis. RESULTS 194 patients (60.8% women; mean age 62.5 ± 16.0 years) were included (76.8% aSAH and 23.2% naSAH). The crude incidence rates per 100,000 person-years of SAH, aSAH, and naSAH were 6.5 (95% CI 5.6-7.5), 5.0 (95% CI 4.2-5.9), and 1.5 (95% CI 1.1-2.0), respectively, and remained stable over time. Compared to aSAH, naSAH patients had higher age (68.8 ± 19.7 yearsvs 60.6 ± 14.2 years; p = 0.012), lower cigarette smoking (17.9%vs 36.4%; p < 0.001) and higher atrial fibrillation (15.7% vs 2.8%; p = 0.005). SAH case-fatality rates within 30-days and 1-year were 28.4% (95% CI 21.4-36.9) and 37.1% (95% CI 29.0-46.7), respectively. The relative proportion of surgically treated patients did not change over time. CONCLUSION We found a low and stable incidence of SAH over the 2011-2020 period. naSAH remained rare and deserves further investigation in larger prospective cohorts.
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Affiliation(s)
- Chiara Ragaglini
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Federico De Santis
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Anna Laura Molliconi
- Department of Internal Medicine, Public Health, Life and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | - Francesco Conversi
- Department of Internal Medicine, Public Health, Life and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | - Enrico Colangeli
- Department of Neurology and Stroke Unit of Avezzano-Sulmona, ASL 1 Avezzano-Sulmona-L’Aquila, L’Aquila, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
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Kam JKP, Dodds JM, Kam JKT, Dawes BH, Ghani M. Outcomes after inter-hospital transfer of intensive care patients with haemorrhagic stroke: a 5-year retrospective review. ANZ J Surg 2023; 93:1957-1963. [PMID: 36947603 DOI: 10.1111/ans.18426] [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: 10/27/2022] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Inter-hospital transfer (IHT) of intensive care patients is a limited resource. We assessed the outcomes of patients with haemorrhagic stroke requiring IHT and intensive care and aimed to identify early prognostic factors of poor neurological outcome. METHODS We conducted a retrospective observational cohort study of patients admitted to a single tertiary intensive care unit (ICU) with haemorrhagic stroke after IHT between January 2014 and December 2018. Primary outcome was poor neurological outcome (modified Rankin Scale ≥4 at time of discharge from hospital or rehabilitation unit). Secondary outcomes were mortality rate, rate of intervention, rate of organ donation surgery (ODS) and potentially avoidable transfer (PAT). PAT was defined as transfer where the patient did not receive an intervention and had a poor neurological outcome. RESULTS Ninety patients were included in this study, 48 with intracerebral haemorrhage (ICH) and 42 with subarachnoid haemorrhage (SAH). Fifty-one (56.7%) patients had a poor neurological outcome, including 30 (33%) who died. Factors significantly associated with poor neurological outcome included age > 80 years, lower presenting Glasgow Coma Score (GCS) and bilaterally fixed and dilated pupils. Stepwise logistic regression demonstrated history of hypertension as significantly associated with poor neurological outcome in patients with ICH (P = 0.021). Seven (7.8%) patients had ODS. Sixty-four (71.1%) patients received intervention and 20 (22.2%) transfers were potentially avoidable. CONCLUSIONS Patients in this cohort are at high risk of poor neurological outcome. Prognostic factors identified in this study may help referring, retrieval and receiving clinicians to discuss futility prior to pursuing IHT.
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Affiliation(s)
- Jeffrey K P Kam
- Department of Intensive Care Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Jarron M Dodds
- Department of Intensive Care Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Jeremy K T Kam
- Department of Neurosurgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Neurosurgery, Monash Health, Melbourne, Victoria, Australia
| | - Bryden H Dawes
- Department of Neurosurgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Manisa Ghani
- Department of Intensive Care Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Roman-Filip I, Morosanu V, Bajko Z, Roman-Filip C, Balasa RI. Non-Aneurysmal Perimesencephalic Subarachnoid Hemorrhage: A Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13061195. [PMID: 36980503 PMCID: PMC10047780 DOI: 10.3390/diagnostics13061195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Spontaneous non-aneurysmal subarachnoid haemorrhage (NAPMSAH) (addressing point 1) is a relatively rare occurrence in clinical settings as it is rarely misdiagnosed and usually involves a significantly better prognosis than the classical aneurysmal pattern. We hereby focused on a comprehensive analysis of this distinct pathological entity with the purpose of analysing possible pathophysiological entities, outcomes and treatment options involving this diagnosis with a focus on demographical, epidemiological and clinical data. The clinical setting includes focal neurological signs related to the anatomical structures, while computer tomography followed by tomographic angiography are the most common diagnosis tools, with a typical hyperdense lesion involving the midbrain, fourth ventricle and subthalamic areas without an angiographic correspondent, such as an aneurysmal pathology. Further investigations can also be used to highlight this diagnosis, such as interventional angiography or magnetic resonance imaging. Given the rarity of this condition and its relatively better prognosis, treatment options usually remain conservative. In the present review, the main characteristics of NAPMSAH are discussed.
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Affiliation(s)
- Iulian Roman-Filip
- Department of Neurology, "George Emil Palade" University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Valentin Morosanu
- Department of Neurology, "George Emil Palade" University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Zoltan Bajko
- Department of Neurology, "George Emil Palade" University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Corina Roman-Filip
- Department of Neurology, "Lucian Blaga" University of Sibiu Faculty of Medicine, 550169 Sibiu, Romania
| | - Rodica Ioana Balasa
- Department of Neurology, "George Emil Palade" University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
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Özdemir Ö, Diren F, Boyalı O, Baysoy B, Kabataş S. Factors Associated with Clinical Outcomes in Spontaneous Subarachnoid Hemorrhage. JOURNAL OF ACADEMIC RESEARCH IN MEDICINE 2022. [DOI: 10.4274/jarem.galenos.2022.98704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Use of A Systemic Inflammatory Response Index to Predict Non-Traumatic Non-Aneurysmal Subarachnoid Hemorrhage Patient Outcomes. J Stroke Cerebrovasc Dis 2022; 31:106863. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/21/2022] Open
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Park H, Son YJ, Hong N, Kim SB. The relationship between non-aneurysmal spontaneous subarachnoid hemorrhage and basilar tip anatomy. J Cerebrovasc Endovasc Neurosurg 2022; 24:232-240. [PMID: 35934810 PMCID: PMC9537650 DOI: 10.7461/jcen.2022.e2022.01.004] [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: 01/18/2022] [Accepted: 03/08/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Non-aneurysmal spontaneous subarachnoid hemorrhage (NASAH) has a good prognosis, but its cause has not been clearly identified. In this study, we assessed the clinical and radiological features of NASAH and suggested an anatomical relationship between the basilar tip anatomy and NASAH. Methods From August 2013 to May 2020, 21 patients were diagnosed with NASAH at our institution. We evaluated the clinical features of NASAH. NASAH was classified into a perimesencephalic pattern and aneurysmal pattern according to the distribution of hemorrhage based on initial brain computed tomography. Digital subtraction angiography was used to classify the basilar tip anatomy into symmetric cranial fusion, symmetric caudal fusion, or asymmetric fusion types. Results Of the 21 patients, twenty patients had a good clinical outcome (modified Rankin Scale (mRS) 1–2; Glasgow Outcome Scale (GOS) 4–5). These patients showed improvement in mRS and Glasgow Coma Scale (GCS) at the last follow-up (P=.003 and P=.016, respectively). Eighteen patients with NASAH (85.7%) had the caudal fusion type, and only three patients with NASAH (14.3%) had the cranial fusion type. Seven patients with the perimesencephalic pattern (77.8%) had the caudal fusion type, and eleven patients with the aneurysmal pattern (91.7%) had the caudal fusion type. Conclusions In NASAH patients, the caudal fusion tends to occur frequently among patients with basilar tip anatomy. In the case of the caudal fusion, the perforators around the basilar tip would be more susceptible to hemodynamic stress, which could contribute to the occurrence of NASAH.
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Affiliation(s)
- Hangeul Park
- Department of Neurosurgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young-Je Son
- Department of Neurosurgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Noah Hong
- Department of Neurosurgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seung Bin Kim
- Intensive Care Units, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
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Retrospective 6 month-outcomes and prognostic factors following spontaneous angiogram-negative non-perimesencephalic subarachnoid hemorrhage. J Clin Neurosci 2021; 96:12-18. [PMID: 34959170 DOI: 10.1016/j.jocn.2021.12.017] [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] [Received: 10/14/2021] [Revised: 11/23/2021] [Accepted: 12/14/2021] [Indexed: 01/12/2023]
Abstract
Our objective was to analyze functional outcomes and prognostic factors in patients suffering from angiogram-negative non-perimesencephalic subarachnoid hemorrhage (non-PMH). In total, 1601 patients presenting with spontaneous SAH between January 2009 to December 2019 admitted to our institution were reviewed. Among them, 51 patients with angiogram negative non-perimesencephalic subarachnoid hemorrhage were analyzed. We divided patients into groups according to hemorrhage pattern and duration. Prognostic factors were assessed according to initial neurologic grade, early hydrocephalus, fisher grade, and duration of hemorrhage. Outcomes were assessed according to the modified Rankin Scale after 6 months. Overall, 41 patients (80.3%) with angiogram-negative non-PMH achieved a favorable outcome. In univariate analysis, good initial neurologic grade, absence of early hydrocephalus, non-Fisher-type 3 bleeding pattern, and short term hemorrhage (blood wash out <7 days after onset) duration were significantly associated with a favorable outcome. In multivariate analysis, a non-Fisher-type 3 hemorrhagic pattern (p < 0.05) and good initial neurologic state (p < 0.01) were independent predictors of favorable outcomes in angiogram-negative non-PMH patients. Patients with angiogram-negative non-PMH generally had favorable outcomes. A non-Fisher-type 3 hemorrhagic pattern and good initial neurologic state were prognostic factors of a favorable outcome in non-PMH. Furthermore, patients with long-term SAH were more likely to develop hydrocephalus. Evaluating the pattern and duration of subarachnoid hemorrhage may allow better prediction of outcomes in patients with angiogram negative and non-PMH.
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Yoon W, Kim JH, Roh H, Kwon TH. Arterial Wall Imaging in Angiographically Occult Spontaneous Subarachnoid Hemorrhage : New Insight into the Usual Suspect. J Korean Neurosurg Soc 2021; 65:245-254. [PMID: 34915680 PMCID: PMC8918240 DOI: 10.3340/jkns.2021.0120] [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: 05/20/2021] [Accepted: 10/06/2021] [Indexed: 11/27/2022] Open
Abstract
Objective The etiology of angiographically occult spontaneous subarachnoid hemorrhage (AOsSAH) is unclear. Threedimensional (3D) high-resolution vessel wall magnetic resonance imaging (HVM) might be useful in detecting the hidden arterial wall angiopathy in patients with AOsSAH. We aimed to demonstrate the feasibility of HVM for detecting the arterial cause of AOsSAH. Methods Patients, who were diagnosed with AOsSAH in the first evaluations and underwent HVM, were enrolled. Their clinical and radiologic data were retrospectively reviewed. Especially, focal enhancement of arterial wall on HVM and repetitive catheterized angiograms were precisely compared. Results Among 251 patients with spontaneous SAH, 22 patients were diagnosed with AOsSAH in the first evaluations (8.76%). After excluding three patients who did not undergo 3D-HVM, 19 patients were enrolled and classified as convexal (n=2) or perimesencephalic (n=4), and diffuse (n=13) groups. In convexal and perimesencephalic groups, no focal enhancement on HVM and no positive findings on repetitive angiography were noted. In diffuse group, 10 patients showed focal enhancement of arterial wall on HVM (10/13, 76.9%). Repeated angiography with 3D reconstruction revealed four patients of angiographically positive causative arteriopathy and possible lesion in one case in the concordant location of intramural enhancement on 3D-HVM (5/10, 50%). Three of them were treated with endovascular stent insertion. All patients, except one, recovered with good clinical outcome (3-month modified Rankin score, 0 and 1). Conclusion 3D-HVM was useful in detecting hidden true arteriopathy in AOsSAH. It may provide new insights into the etiologic investigation of AOsSAH by proving information about the arterial wall status.
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Affiliation(s)
- Wonki Yoon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jang Hun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Haewon Roh
- Department of Neurosurgery, Armed Forces Capital Hospital, Seongnam, Korea
| | - Taek-Hyun Kwon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Bruder M, Kashefiolasl S, Brawanski N, Keil F, Won SY, Seifert V, Konczalla J. Vitamin K Antagonist (Phenprocoumon) and Subarachnoid Hemorrhage: A Single-Center, Matched-Pair Analysis. Neurocrit Care 2021; 33:105-114. [PMID: 31659679 DOI: 10.1007/s12028-019-00868-4] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND Demographic changes are leading to an aging society with a growing number of patients relying on anticoagulation, and vitamin K antagonists (VKA) are still widely used. As mortality and functional outcomes are worse in case of VKA-associated hemorrhagic stroke, phenprocoumon treatment seems to be a negative prognostic factor in case of subarachnoid hemorrhage (SAH). The purpose of this study was to analyze whether phenprocoumon treatment does worsen the outcome after non-traumatic SAH. METHODS All patients treated for non-traumatic SAH between January 2007 and December 2016 in our institution were retrospectively analyzed. After exclusion of patients with anticoagulant or antiplatelet treatment other than phenprocoumon, we analyzed 1040 patients. Thirty-three patients (3%) of those were treated with continuous phenprocoumon. In total, 132 out of all 1007 patients without anticoagulant treatment of the remaining patients were matched as control group (ratio = 1:4). RESULTS Patients with phenprocoumon treatment were significantly older (66.5 years vs. 53.9 years; p < .0001), and admission status was significantly more often poor (66.7% vs. 41.8%, p = .007) compared to all patients without anticoagulant treatment. Further, bleeding pattern and rates of early hydrocephalus did not differ. Matched-pair analysis revealed a significant higher rate of angio-negative SAH in the study group (p = .001). Overall rates of hemorrhagic or thromboembolic complications did not differ (21.4% vs. 18.8%; NS) but were more often fatal, and 30-day mortality rate was significantly higher in the phenprocoumon group than in patients of the matched-pair control group (33% vs. 24%; p < .001). 30% of the phenprocoumon group and 37% of the matched-pair control group reached favorable outcome. However, poor outcome was strong associated with the reason for phenprocoumon treatment. CONCLUSION Patients with phenprocoumon treatment at the time of SAH are significantly older, admission status is worse, and 30-day mortality rates are significantly higher compared to patients without anticoagulant treatment. However, outcome at 6 months did not differ to the matched-pair control group but seems to be strongly associated with the underlying cardiovascular disease. Treatment of these patients is challenging and should be performed on an interdisciplinary base in each individual case. Careful decision-making regarding discontinuation and bridging of anticoagulation and close observation is mandatory.
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Affiliation(s)
- Markus Bruder
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.
| | | | - Nina Brawanski
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Fee Keil
- Department of Neuroradiology, Goethe University, Frankfurt am Main, Germany
| | - Sae-Yeon Won
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
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Neuroimaging of Pediatric Intracerebral Hemorrhage. J Clin Med 2020; 9:jcm9051518. [PMID: 32443470 PMCID: PMC7290500 DOI: 10.3390/jcm9051518] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 01/20/2023] Open
Abstract
Hemorrhagic strokes account for half of all strokes seen in children, and the etiologies of these hemorrhagic strokes differ greatly from those seen in adult patients. This review gives an overview about incidence and etiologies as well as presentation of children with intracerebral hemorrhage and with differential diagnoses in the emergency department. Most importantly it describes how neuroimaging of children with intracerebral hemorrhage should be tailored to specific situations and clinical contexts and recommends specific imaging protocols for acute and repeat imaging. In this context it is important to keep in mind the high prevalence of underlying vascular lesions and adapt the imaging protocol accordingly, meaning that vascular imaging plays a key role regardless of modality. Magnetic resonance imaging (MRI), including advanced sequences, should be favored whenever possible at the acute phase.
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Alhoobi M, Abu-Qadous F, Khan M, Shaaban A, Shaikh N, Hammadi F, Abu-Jarir R, Albanna W, Alrumaihi G, Belkhair S, Babu AR, Ayyad A. Ten Years' Experiences in the Treatment of Nonaneurysmal Subarachnoid Hemorrhage: A Retrospective Analysis of Outcome Parameters in a Single-Center Study. Asian J Neurosurg 2020; 15:315-321. [PMID: 32656125 PMCID: PMC7335133 DOI: 10.4103/ajns.ajns_315_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022] Open
Abstract
Objectives: Subarachnoid hemorrhage (SAH) with negative angiographic findings has a heterogeneous nature with variations in clinical course and outcome as compared to the aneurysmal SAH. It makes up to 15% of the spontaneous SAH and is characterized by milder clinical presentation. The purpose of this study was the analyses of risk factors, clinical observations, radiologic characteristics, and outcome in patients with nonaneurysmal SAH (NA-SAH). Patients and Methods: In a retrospective design, 77 consecutive patients with NA-SAH were recruited from May 2008, to October 2018. All patients underwent conventional cerebral angiography. We stratified patients into two groups based on the distribution of blood on their CT scan into perimesencephalic (PM) and non-PM (NPM) SAH. We performed the Outcome using Glasgow Coma Scale (GCS) and modified Rankin scale (favorable mRS 0–2 vs. unfavorable mRS 3–6). Data were analyzed using IBM® SPSS® Statistics V22.0. Results: The mean age at presentation was 48.5 ± 8.4 years with male predominance (71.4%). About 76.7% of the patients had headache and vomiting, most of the patients (75.3%) presented with GCS 15 at initial clinical presentation (61.03%) had NPM versus (38.96%) with PM characters in computed tomography scans. Fourteen (17.9%) patients developed hydrocephalus and 12 (15.3%) needed external ventricular drain placement, while none of the patients needed permanent shunt placement. However, all patients had a favorable clinical and functional outcome at discharge and at late follow-up (up to 3 months). Conclusions: NA-SAH does not affect the short- and long-term prognosis. In our results, the pattern of bleeding affects the initial presentation, clinical course, and complications. The clinical and functional outcomes in the majority of our patients were comparable in both groups with good prognosis. Hypertension, smoking, and elevated venous pressure, such as a history of deep venous thrombosis and asthma might be considered as a risk factor.
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Affiliation(s)
- Mohammed Alhoobi
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Fatma Abu-Qadous
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohsin Khan
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Shaaban
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Nissar Shaikh
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Firas Hammadi
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Raed Abu-Jarir
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Walid Albanna
- Department of Neurosurgery, RWTH, Aachen University, Aachen, Germany
| | - Ghaya Alrumaihi
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Arun R Babu
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Ali Ayyad
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
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Kimura T, Kamide T, Onodera K, Tabata S, Shibata A, Suzuki K, Takeda R, Ikeda T, Kikkawa Y, Iihoshi S, Kohyama S, Kurita H. Clinical Features of Neurogenic Pulmonary Edema in Patients with Subarachnoid Hemorrhage. World Neurosurg 2019; 135:e505-e509. [PMID: 31863887 DOI: 10.1016/j.wneu.2019.12.060] [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] [Received: 08/27/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by acute onset after central nervous system injury. Here, we investigated the clinical features of NPE in patients with subarachnoid hemorrhage (SAH). METHODS We retrospectively analyzed a total of 350 patients with SAH who were treated at our hospital from April 2014 to September 2017. Patient demographics, aneurysm size and location, clinical characteristics, and patient outcomes were reviewed and compared between an NPE and a non-NPE group. RESULTS Sixteen patients (4.6%) presented with NPE at admission. Ten of these (62.5%) recovered from NPE immediately, and ventilatory support was withdrawn within 2 days from onset. A univariate analysis showed that patients with NPE were younger (P = 0.04), had a higher rate of vertebral artery dissection (P < 0.01), more severe World Federation of Neurosurgical Societies (WFNS) grades (P = 0.01), and lower systolic blood pressure on admission (P = 0.01). A multivariate analysis revealed significant differences in the frequency of vertebral artery dissection (odds ratio 4.83, 95% confidence interval 1.50-15.56, P < 0.01) and in WFNS grades (odds ratio 3.73, 95% confidence interval 1.02-13.66, P = 0.04) between the groups. No significant group differences were found in other factors including heart rate, radiographic sign (Fisher grade), aneurysm size and location, blood sample tests on admission, and neurologic outcomes. CONCLUSIONS Vertebral artery dissection and severe WFNS grade on admission were confirmed as significant risk factors for NPE. However, neurologic outcomes at discharge did not differ between groups, suggesting that poor outcomes due to NPE could be reduced by appropriate diagnosis and treatment.
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Affiliation(s)
- Tatsuki Kimura
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Tomoya Kamide
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan.
| | - Koki Onodera
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Shinya Tabata
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Aoto Shibata
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Kaima Suzuki
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Ririko Takeda
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Toshiki Ikeda
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Yuichiro Kikkawa
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Satoshi Iihoshi
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Shinya Kohyama
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Hiroki Kurita
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
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Mohan M, Islim AI, Rasul FT, Rominiyi O, deSouza RM, Poon MTC, Jamjoom AAB, Kolias AG, Woodfield J, Patel K, Chari A, Kirollos R. Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis. Acta Neurochir (Wien) 2019; 161:2013-2026. [PMID: 31410556 PMCID: PMC6739283 DOI: 10.1007/s00701-019-04025-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/25/2019] [Indexed: 02/07/2023]
Abstract
Background In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to systematically evaluate the delayed investigation strategies and clinical outcomes in these cases, often described as “non-aneurysmal” SAH (naSAH). Methods A systematic review was performed in concordance with the PRISMA checklist. Pooled proportions of primary outcome measures were estimated using a random-effects model. Results Fifty-eight studies were included (4473 patients). The cohort was split into perimesencephalic naSAH (PnaSAH) (49.9%), non-PnaSAH (44.7%) and radiologically negative SAH identified on lumbar puncture (5.4%). The commonest initial vascular imaging modality was digital subtraction angiography. A vascular abnormality was identified during delayed investigation in 3.9% [95% CI 1.9–6.6]. There was no uniform strategy for the timing or modality of delayed investigations. The pooled proportion of a favourable modified Rankin scale outcome (0–2) at 3–6 months following diagnosis was 92.0% [95% CI 86.0–96.5]. Complications included re-bleeding (3.1% [95% CI 1.5–5.2]), hydrocephalus (16.0% [95% CI 11.2–21.4]), vasospasm (9.6% [95% CI 6.5–13.3]) and seizure (3.5% [95% CI 1.7–5.8]). Stratified by bleeding pattern, we demonstrate a higher rate of delayed diagnoses (13.6% [95% CI 7.4–21.3]), lower proportion of favourable functional outcome (87.2% [95% CI 80.1–92.9]) and higher risk of complications for non-PnaSAH patients. Conclusion This study highlights the heterogeneity in delayed investigations and outcomes for patients with naSAH, which may be influenced by the initial pattern of bleeding. Further multi-centre prospective studies are required to clarify optimal tailored management strategies for this heterogeneous group of patients. Electronic supplementary material The online version of this article (10.1007/s00701-019-04025-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Midhun Mohan
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust and University of Liverpool, Liverpool, UK
| | - Abdurrahman I Islim
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust and University of Liverpool, Liverpool, UK
| | - Fahid T Rasul
- Department of Neurosurgery, Queen's Hospital, Romford, UK
| | - Ola Rominiyi
- Department of Neurosurgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Aimun A B Jamjoom
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Julie Woodfield
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Krunal Patel
- Division of Neurosurgery, Krembil Research Institute, Toronto Western Hospital, University Health Network and University of Toronto, Toronto, Canada
| | - Aswin Chari
- Institute of Child Health, University College London, London, UK.
- Department of Neurosurgery, Great Ormond Street Hospital, Great Ormond Street, WC1N 3JH, London, UK.
| | - Ramez Kirollos
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
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15
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Kim SE, Kim BJ, Cho SS, Kim HC, Jeon JP. The Incidence of Hydrocephalus and Shunting in Patients with Angiogram-Negative Subarachnoid Hemorrhage: An Updated Meta-Analysis. World Neurosurg 2018; 119:e216-e227. [PMID: 30048789 DOI: 10.1016/j.wneu.2018.07.119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the incidence of hydrocephalus and implanted shunts in angiogram-negative subarachnoid hemorrhage (SAH) according to hemorrhage patterns: perimesencephalic SAH (PMH) versus non-PMH. METHODS The online database literature from January 1990 to November 2017 was systematically reviewed. A fixed-effect model was used when heterogeneity was <50%. A Begg funnel plot was used to assess publication bias. An additional trim and fill method was used to estimate the number of missing studies. A subgroup analysis with studies, which defined angiogram-negative SAH using repeated angiography or computed tomography angiography, was further performed. RESULTS A total of 28 articles including 2577 patients were enrolled. Patients with PMH showed a significantly decreased incidence of hydrocephalus (odds ratio [OR], 0.269; 95% confidence interval [CI], 0.208-0.348) and shunts (OR, 0.263; 95% CI, 0.169-0.411) than did patients without PMH. A subgroup analysis of 7 studies with 675 patients showed less hydrocephalus in patients with PMH than in patients without PMH (OR, 0.358; 95% CI, 0.161-0.793), with possible publication bias. Shunt procedures were marginally less common in patients with PMH compared with those patients without PMH (OR, 0.490; 95% CI, 0.236-1.018) with possible publication bias. After correction of the forest plot, the adjusted OR was 0.617 (95% CI, 0.251-1.513) for hydrocephalus and 0.618 (95% CI, 0.310-1.232) for shunts, suggesting no significant relationships between PMH and the risk of hydrocephalus or shunting. CONCLUSIONS Hydrocephalus and shunts were more evident in non-PMH than PMH. However, subgroup analyses did not show significant associations between PMH and lower risks of these events after correction for possible publication bias. Further meta-analyses based on individual patient data are necessary.
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Affiliation(s)
- Sung-Eun Kim
- Department of Emergency Medicine, Seoul Emergency Operations Center, Seoul, Korea
| | - Bong Jun Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Steve S Cho
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heung Cheol Kim
- Department of Radiology, Hallym University College of Medicine, Chuncheon, Korea
| | - Jin Pyeong Jeon
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea; Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea.
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16
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Lee SU, Hong EP, Kim BJ, Kim SE, Jeon JP. Delayed Cerebral Ischemia and Vasospasm After Spontaneous Angiogram-Negative Subarachnoid Hemorrhage: An Updated Meta-Analysis. World Neurosurg 2018; 115:e558-e569. [PMID: 29689403 DOI: 10.1016/j.wneu.2018.04.096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To report clinical outcomes of delayed cerebral ischemia (DCI) and vasospasm in angiogram-negative subarachnoid hemorrhage (SAH) according to hemorrhage patterns, perimesencephalic hemorrhage (PMH) and non-PMH. METHODS Online databases from January 1990 to December 2017 were systematically reviewed. A fixed-effects model was used to control heterogeneity. To resolve publication bias, the trim and fill method was used to estimate number of missing studies and adjusted odds ratio (OR). Subgroup analysis of data from studies that defined angiogram-negative subarachnoid hemorrhage by angiography repeated at least twice or computed tomography angiography was performed. RESULTS Among 24 studies including 2083 patients, 23/985 patients (2.3%) with PMH and 144/1098 patients (13.1%) with non-PMH had DCI, indicating that patients with PMH experienced significantly lower DCI than patients with non-PMH (OR = 0.219; 95% confidence interval [CI], 0.144-0.334). Regarding vasospasm, 99/773 patients (12.8%) with PMH and 231/922 patients (25.1%) with non-PMH exhibited vasospasm, indicating that patients with PMH experienced significantly lower vasospasm than patients with non-PMH (OR = 0.445; 95% CI, 0.337-0.589). Funnel plots show asymmetry indicating possible publication bias. After trimming 10 studies for DCI and 7 for vasospasm, the adjusted ORs remained significant between PMH and lower risks of DCI and vasospasm. Subgroup analysis of 789 patients in 8 studies showed a lower risk of DCI (OR = 0.268; 95% CI, 0.151-0.473) and vasospasm (OR = 0.346; 95% CI, 0.221-0.538) in patients with PMH. CONCLUSIONS PMH showed a significantly lower risk of DCI and vasospasm than non-PMH. Clinical outcomes of angiogram-negative subarachnoid hemorrhage, based on meta-analysis of individual patient data, need to be investigated.
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Affiliation(s)
- Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Eun Pyo Hong
- Department of Medical Genetics, Hallym University College of Medicine, Chuncheon, Korea
| | - Bong Jun Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Sung-Eun Kim
- Department of Emergency Medicine, Seoul Emergency Operations Center, Seoul, Korea
| | - Jin Pyeong Jeon
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea; Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea.
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17
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Zheng J, Cheng C, Zhou C, Chen H, Guo Z, Sun X. The Clinical Value of d-Dimer Level in Patients with Nonaneurysmal Subarachnoid Hemorrhage. World Neurosurg 2018; 114:e1161-e1167. [PMID: 29614358 DOI: 10.1016/j.wneu.2018.03.165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/23/2018] [Accepted: 03/23/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE More nonaneurysmal subarachnoid hemorrhage (NaSAH) are found in clinical practice. However, the precise mechanisms in which d-dimer level is associated with clinical condition in patients with NaSAH remain unclear. But even more, the data assessing the risk of clinical course in the patients with NaSAH are scarce. Our objective was to investigate whether d-dimer levels correlated with complication and outcome in patients with NaSAH. METHODS Between February 2013 and May 2017, 92 patients suffering from NaSAH were treated in our hospital. Patient characteristics, radiologic features, laboratory findings, complications, and outcomes were analyzed retrospectively. Patients were stratified into the perimesencephalic (PM) subarachnoid hemorrhage (SAH) group and the nonperimesencephalic (NPM) SAH group according to the bleeding type, and the NPM-SAH group was further divided into 2 subgroups into the NPM-elevated group and the NPM-normal group based on the value of the d-dimer. After statistical analysis, the NPM-SAH and PM-SAH groups were compared; the same was true for the NPM-elevated group and the NPM-normal group. RESULTS The rate of complications in the NPM-SAH group was higher than in the PM-SAH group, including early hydrocephalus, delayed cerebral ischemia, clinical vasospasm, pneumonia, and hyponatremia. Our results showed that d-dimer levels in patients with NPM-SAH were more elevated than in those with PM-SAH. Further analysis of subgroups demonstrated that patients with elevated d-dimer levels had a higher incidence of complications than those with normal d-dimer levels, especially the risks of shunt-dependent hydrocephalus and pneumonia. In addition, disability, and even death, could be seen in patients with higher levels of d-dimer, but the long-term outcomes were not particularly obvious between these groups. CONCLUSIONS Elevated d-dimer levels on admission were significantly associated with complication in patients with NPM-SAH. In addition to conventional radiologic diagnosis, d-dimer levels can increase the ability of a rapid differential diagnosis between NPM-SAH and PM-SAH.
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Affiliation(s)
- Jianfeng Zheng
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, People's Republic of China
| | - Chongjie Cheng
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, People's Republic of China
| | - Chao Zhou
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, People's Republic of China
| | - Hong Chen
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, People's Republic of China
| | - Zongduo Guo
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, People's Republic of China.
| | - Xiaochuan Sun
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, People's Republic of China.
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18
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Leclerc JL, Garcia JM, Diller MA, Carpenter AM, Kamat PK, Hoh BL, Doré S. A Comparison of Pathophysiology in Humans and Rodent Models of Subarachnoid Hemorrhage. Front Mol Neurosci 2018; 11:71. [PMID: 29623028 PMCID: PMC5875105 DOI: 10.3389/fnmol.2018.00071] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/20/2018] [Indexed: 01/03/2023] Open
Abstract
Non-traumatic subarachnoid hemorrhage (SAH) affects an estimated 30,000 people each year in the United States, with an overall mortality of ~30%. Most cases of SAH result from a ruptured intracranial aneurysm, require long hospital stays, and result in significant disability and high fatality. Early brain injury (EBI) and delayed cerebral vasospasm (CV) have been implicated as leading causes of morbidity and mortality in these patients, necessitating intense focus on developing preclinical animal models that replicate clinical SAH complete with delayed CV. Despite the variety of animal models currently available, translation of findings from rodent models to clinical trials has proven especially difficult. While the explanation for this lack of translation is unclear, possibilities include the lack of standardized practices and poor replication of human pathophysiology, such as delayed cerebral vasospasm and ischemia, in rodent models of SAH. In this review, we summarize the different approaches to simulating SAH in rodents, in particular elucidating the key pathophysiology of the various methods and models. Ultimately, we suggest the development of standardized model of rodent SAH that better replicates human pathophysiology for moving forward with translational research.
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Affiliation(s)
- Jenna L Leclerc
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States.,Department of Neuroscience, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville, FL, United States
| | - Joshua M Garcia
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States
| | - Matthew A Diller
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States
| | - Anne-Marie Carpenter
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States
| | - Pradip K Kamat
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States
| | - Brian L Hoh
- Department of Neuroscience, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville, FL, United States.,Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Sylvain Doré
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States.,Department of Neuroscience, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville, FL, United States.,Department of Neurology, Psychiatry, and Pharmaceutics, University of Florida, Gainesville, FL, United States
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19
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Konczalla J, Kashefiolasl S, Brawanski N, Bruder M, Gessler F, Senft C, Berkefeld J, Seifert V, Tritt S. Cerebral Vasospasm-Dependent and Cerebral Vasospasm-Independent Cerebral Infarctions Predict Outcome After Nonaneurysmal Subarachnoid Hemorrhage: A Single-Center Series with 250 Patients. World Neurosurg 2017; 106:861-869.e4. [PMID: 28711533 DOI: 10.1016/j.wneu.2017.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The number of patients with nonaneurysmal subarachnoid hemorrhage (naSAH) has increased during the last decade. Data regarding infarctions in naSAH are still limited. The aim of this study was to identify the rate of cerebral vasospasm (CVS)-dependent and CVS-independent infarctions and their influence on clinical outcomes. METHODS Between 1999 and 2015, 250 patients suffering from naSAH were analyzed retrospectively. A delayed infarction was analyzed whether it was associated with CVS (CVS-dependent infarction) or not (CVS-independent). RESULTS A total of 36 patients (14%) had cerebral infarctions. CVS was detected in 54 patients (22%), and 15 (6%) of them developed infarctions (CVS-dependent). Infarctions without signs of CVS (CVS-independent) occurred in 21 patients (8%). Overall, 86% of the patients had favorable outcome. Patients without cerebral infarctions had the best outcome (91% favorable outcome, 5% mortality rate). Patients with CVS-independent infarctions (57%) as well as patients with CVS-dependent infarctions (53%) had a favorable outcome less often. The mortality rate was also significantly greater in patients with CVS-independent (19%) and CVS-dependent infarctions (33%). A further independent predictor was anticoagulative therapy, which increased during study period and was associated with nonperimesencephalic blood distribution. CONCLUSIONS CVS-dependent and independent infarctions occur in naSAH and contribute to unfavorable outcomes. Whereas CVS-independent infarctions occur in any subgroup, CVS-dependent infarctions seem to be associated with blood pattern (Fisher 3). Anticoagulative therapy seems to be not only a predictor for worse outcome but also for nonperimesencephalic SAH. Accordingly, the proportion of perimesencephalic and nonperimesencephalic SAH changed during the study period (from 2.2:1 to 1:1.7).
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Affiliation(s)
- Juergen Konczalla
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany.
| | - Sepide Kashefiolasl
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Nina Brawanski
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Markus Bruder
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Florian Gessler
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Christian Senft
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Stephanie Tritt
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt am Main, Germany
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20
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Coelho LGBSA, Costa JMD, Silva EIPA. Non-aneurysmal spontaneous subarachnoid hemorrhage: perimesencephalic versus non-perimesencephalic. Rev Bras Ter Intensiva 2017; 28:141-6. [PMID: 27410409 PMCID: PMC4943051 DOI: 10.5935/0103-507x.20160028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/29/2016] [Indexed: 12/23/2022] Open
Abstract
Objective To compare the clinical evolution of perimesencephalic subarachnoid
hemorrhage and non-perimesencephalic subarachnoid hemorrhage. Methods The study was conducted retrospectively in a tertiary hospital center in the
north region of Portugal. Included patients had no identifiable cause for
subarachnoid hemorrhage. Several epidemiologic, clinical and imaging aspects
were statistically analyzed, taking into account the differences in
perimesencephalic subarachnoid hemorrhage and non-perimesencephalic
subarachnoid hemorrhage. Results Sixty-two patients met the inclusion criteria (46.8% - perimesencephalic
subarachnoid hemorrhage; 53.2% - non-perimesencephalic subarachnoid
hemorrhage). Demographic and clinical background characteristics were
similar in both groups. Complications were more frequent in patients with
non-perimesencephalic subarachnoid hemorrhage - 84.8% of the patients had at
least one complication versus 48.3% in perimesencephalic subarachnoid
hemorrhage. Vasospasm, infection and hydrocephaly were the most common
complications (each was detected more frequently in the
non-perimesencephalic subarachnoid hemorrhage group than in
perimesencephalic subarachnoid hemorrhage group). Two patients died, both
had a non-perimesencephalic subarachnoid hemorrhage. The median inpatient
time was longer in the non-perimesencephalic subarachnoid hemorrhage group
(21 versus 14 days). No incidents of rebleeding were reported during the
follow-up period (mean time of 15 ± 10.3 months). Conclusion Perimesencephalic subarachnoid hemorrhage and non-perimesencephalic
subarachnoid hemorrhage are two different entities that have different
clinical outcomes, namely in terms of complication rate and median inpatient
time. The management of these patients should respect this difference to
improve treatment and optimize health care resources.
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21
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Hafez A, Numminen J, Rahul R, Järveläinen J, Niemelä M. Perimesencephalic subarachnoid hemorrhage with a positive angiographic finding: case report and review of the literature. Acta Neurochir (Wien) 2016; 158:1045-9. [PMID: 27106848 DOI: 10.1007/s00701-016-2801-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 04/04/2016] [Indexed: 11/29/2022]
Abstract
The vast majority of perimesencephalic subarachnoid hemorrhage cases are reported as negative-finding etiologies. Recently, high-resolution images allowed us to overcome the previous difficulty of finding the source of bleeding, which underlies the concept of a "negative finding". We discovered a venous etiology, hidden behind the tip of the basilar artery; namely, the lateral pontine vein. Here, we review the literature on perimesencephalic subarachnoid hemorrhage and on venous aneurysm. We highlight this type of aneurysm as a candidate source of perimesencephalic hemorrhage. This case may change our way of dealing with what we have termed a negative finding of subarachnoid hemorrhage.
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Affiliation(s)
- Ahmad Hafez
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland.
| | - Jussi Numminen
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
| | - Raj Rahul
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
| | - Juha Järveläinen
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
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Konczalla J, Kashefiolasl S, Brawanski N, Lescher S, Senft C, Platz J, Seifert V. Cerebral vasospasm and delayed cerebral infarctions in 225 patients with non-aneurysmal subarachnoid hemorrhage: the underestimated risk of Fisher 3 blood distribution. J Neurointerv Surg 2016; 8:1247-1252. [PMID: 26847333 DOI: 10.1136/neurintsurg-2015-012153] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/14/2016] [Accepted: 01/15/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Recent data have shown increasing numbers of non-aneurysmal subarachnoid hemorrhage (NASAH). However, data are limited and often only small series have been published. Our objective was to analyze the rate of cerebral vasospasm (CVS), delayed cerebral infarction (DCI), and their influence on the clinical outcome, especially in patients with diffuse Fisher 3 bleeding pattern NASAH (Fi3). METHODS Between 1999 and 2014, 225 patients had NASAH. CVS, DCI, and outcome (according to the modified Rankin Scale at 6 months) were analyzed retrospectively. Patients were stratified according to the bleeding type. After univariate analysis a multivariate analysis was performed and NASAH Fi3 was also compared with aneurysmal SAH Fi3. RESULTS Patient characteristics and the outcome of perimesencephalic (PM) and non-PM (NPM) SAH were similar. Excluding Fi3, PM and NPM without Fi3 had similar patient characteristics, clinical course, and outcome. In particular, the Fi3 subgroup had a significantly increased risk of CVS, DCI, unfavorable outcome, hydrocephalus, and death. Early hydrocephalus was associated with Fi3 and intraventricular hemorrhage. The multivariate regression model showed the variables elderly patients, Fi3, and early hydrocephalus as independent and significant predictors for an unfavorable outcome. A further comparison of NASAH Fi3 with aneurysmal SAH Fi3 showed similar characteristics, CVS rate, and mortality. CONCLUSIONS Patients with NASAH without a Fi3 bleeding pattern had a similar excellent outcome to patients with PM-SAH. Patients with Fi3 had a high risk for early hydrocephalus, CVS, DCI, and an unfavorable outcome, similar to patients with aneurysmal SAH. After multivariate analysis, early hydrocephalus, elderly patients, and Fi3 were identified as negative prognostic factors. Therefore, patients with Fi3 are at risk and need careful clinical observation.
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Affiliation(s)
- Juergen Konczalla
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Sepide Kashefiolasl
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Nina Brawanski
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Stephanie Lescher
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Christian Senft
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Johannes Platz
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
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Isolated Cranial Nerve-III Palsy Secondary to Perimesencephalic Subarachnoid Hemorrhage. Case Rep Neurol Med 2016; 2016:6319548. [PMID: 26949557 PMCID: PMC4753334 DOI: 10.1155/2016/6319548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 12/28/2015] [Indexed: 11/17/2022] Open
Abstract
We describe isolated cranial nerve-III palsy as a rare clinical finding in a patient with perimesencephalic subarachnoid hemorrhage. In this unusual case, the patient presented with complete cranial nerve-III palsy including ptosis and pupillary involvement. Initial studies revealed subarachnoid hemorrhage in the perimesencephalic, prepontine, and interpeduncular cisterns. Angiographic studies were negative for an intracranial aneurysm. The patient's neurological deficits improved with no residual deficits on follow-up several months after initial presentation. Our case report supports the notion that patients with perimesencephalic subarachnoid hemorrhage have an excellent prognosis. Our report further adds a case of isolated cranial nerve-III palsy as a rare initial presentation of this type of bleeding, adding to the limited body of the literature.
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Canneti B, Mosqueira AJ, Nombela F, Gilo F, Vivancos J. Spontaneous Subarachnoid Hemorrhage with Negative Angiography Managed in a Stroke Unit: Clinical and Prognostic Characteristics. J Stroke Cerebrovasc Dis 2015; 24:2484-90. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/18/2015] [Accepted: 06/14/2015] [Indexed: 11/26/2022] Open
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Martin SCG, Teo MKCH, Young AMH, Godber IM, Mandalia SS, St George EJ, McGregor C. Defending a traditional practice in the modern era: The use of lumbar puncture in the investigation of subarachnoid haemorrhage. Br J Neurosurg 2015; 29:799-803. [PMID: 26373397 DOI: 10.3109/02688697.2015.1084998] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Acute severe headache is a common medical presentation, and a common area of diagnostic uncertainty. Subarachnoid haemorrhage (SAH) is the cause in a minority of patients and has a high rate of morbidity and mortality. Therefore, its conclusive diagnosis with computed tomography (CT) or lumbar puncture (LP) is paramount. With advancement in imaging technology, emerging evidence now suggests that LP is no longer required for a subset of patients as CT has 100% sensitivity in detecting SAH, when performed under specific conditions. OBJECTIVES To assess the proportion of patients with conclusive CSF xanthochromia results following a negative CT scan in suspected SAH to determine the diagnostic efficacy of LP. METHODS CSF bilirubin and oxyhaemoglobin spectrophotometric absorbance data from all centres in a regional health board were identified for consecutive patients over a 6-month period. Results were stratified as conclusive (positive or negative), or inconclusive according to national guidelines. RESULTS 239 of 255 (93.7%) results were conclusive: 89.0% were negative (227 of 255). 4.7% of results were positive (12 of 255), revealing 4 cerebral aneurysms requiring treatment. 16 out of 255 (6.3%) samples were inconclusive, yielding 1 aneurysm requiring treatment. In the same period, there were 27 CT-positive cases of SAH. CONCLUSIONS LP has a high diagnostic yield, eliminating the need for neurosurgical opinion or investigation in almost 90% of cases. The test is both cost and time efficient and subjects only a small number of patients to the radiation and contrast risks of angiography.
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Affiliation(s)
- Sean C G Martin
- a Department of Acute Medicine , Wishaw General Hospital , Wishaw , UK.,b Department of Neurosurgery , Institute of Neurological Science , Glasgow , UK.,d Emergency Department, John Radcliffe Hospital , Oxford , UK
| | - Mario K C H Teo
- b Department of Neurosurgery , Institute of Neurological Science , Glasgow , UK
| | - Adam M H Young
- b Department of Neurosurgery , Institute of Neurological Science , Glasgow , UK
| | - Ian M Godber
- c Department of Clinical Biochemistry , Monklands Hospital , Airdrie , UK
| | | | - Edward J St George
- b Department of Neurosurgery , Institute of Neurological Science , Glasgow , UK
| | - Calum McGregor
- a Department of Acute Medicine , Wishaw General Hospital , Wishaw , UK
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Rahme R, Vyas NA. Recurrent Perimesencephalic Subarachnoid Hemorrhage After 12 Years: Missed Diagnosis, Vulnerable Anatomy, or Random Events? World Neurosurg 2015. [PMID: 26210714 DOI: 10.1016/j.wneu.2015.07.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Perimesencephalic subarachnoid hemorrhage (PMSAH) is a well-defined subtype of angiogram-negative SAH, characterized by a benign natural history and a virtually nonexistent risk of recurrence. Few case reports of recurrent PMSAH exist in the literature, all occurring after relatively short time intervals ranging from 5 days to 31 months, mostly in patients on antithrombotic therapy. We present a unique case of ultra-late PMSAH recurrence after 12 years, in a patient not receiving antithrombotic medications. CASE DESCRIPTION A woman presented with 2 similar episodes of sudden-onset severe headache and neck pain, without associated neurologic deficits: a first episode at the age of 48 years and a second at 60 years. In each instance, the pattern of hemorrhage was consistent with PMSAH, platelet count and coagulation tests were normal, and a full etiologic work-up, including CTA, catheter angiography, and magnetic resonance imaging, failed to reveal an underlying vascular or tumoral etiology. The patient had a favorable clinical course each time. CONCLUSIONS Although exceptional, recurrence of PMSAH is not impossible. If the 2 events are assumed to be random and independent of each other, binomial statistics yield approximately a 79 per billion chance of 2 or more episodes occurring over an 80-year lifetime. However, other possibilities should be kept in mind, including tiny and radiographically occult vascular lesions or particular venous anatomy predisposing patients to recurrent bouts of PMSAH. Patients should not be told that the risk of recurrence is zero, but that it is close to zero.
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Affiliation(s)
- Ralph Rahme
- Inova Neuroscience Institute, and Department of Neurosciences, Virginia Commonwealth University School of Medicine - Inova Campus, Falls Church, Falls Church, Virginia, USA
| | - Nilesh A Vyas
- Inova Neuroscience Institute, and Department of Neurosciences, Virginia Commonwealth University School of Medicine - Inova Campus, Falls Church, Falls Church, Virginia, USA.
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Ellis JA, McDowell MM, Mayer SA, Lavine SD, Meyers PM, Connolly ES. The role of antiplatelet medications in angiogram-negative subarachnoid hemorrhage. Neurosurgery 2015; 75:530-5; discussion 534-5. [PMID: 25072111 DOI: 10.1227/neu.0000000000000490] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The use of antiplatelet medications has greatly expanded and this has been associated with an increased rate of complications after aneurysmal subarachnoid hemorrhage (SAH). The influence of antiplatelet medications on outcomes after non-aneurysmal SAH is unknown. OBJECTIVE To analyze the frequency and impact on outcome of antiplatelet medication use among patients with angiogram-negative SAH. METHODS An analysis of patients within the Columbia University SAH Outcomes Project database was performed. All patients who underwent catheter cerebral angiography after presenting with nontraumatic SAH between 1996 and 2013 were included. Outcomes were assessed by using the modified Rankin Scale. RESULTS A total of 1351 patients underwent catheter angiography for evaluation of SAH. Of these, 173 (13%) were designated angiogram-negative. The fraction of patients presenting with angiogram-negative SAH as well as the frequency of antiplatelet use among these patients significantly increased during the study period. Antiplatelet use was more commonly associated with angiogram-negative SAH than with angiogram-positive SAH (27% vs 14%, P = .001). At 14 days after presentation, poor outcome was significantly more frequent among patients who took antiplatelet agents than among those who did not (38% vs 20%, P = .017). This effect was also seen after multivariate analysis (odds ratio, 2.58; P = .034), although no difference was observed by 12 months (P > .05). CONCLUSION Antiplatelet medication use is associated with poor early, but not late, outcomes after angiogram-negative SAH. Corresponding increased rates of antiplatelet medication use and angiogram-negative SAH may be related. Additional studies are needed to confirm this association.
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Affiliation(s)
- Jason A Ellis
- *Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and ‡Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Konczalla J, Schmitz J, Kashefiolasl S, Senft C, Seifert V, Platz J. Non-aneurysmal subarachnoid hemorrhage in 173 patients: a prospective study of long-term outcome. Eur J Neurol 2015; 22:1329-36. [PMID: 26130053 DOI: 10.1111/ene.12762] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 04/27/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE In some patients with subarachnoid hemorrhage (SAH) a bleeding source cannot be identified. Perimesencephalic (PM) SAH is assumed to have an excellent outcome. Our objective was to analyze the long-term physical and psychological outcome of patients after non-aneurysmal SAH. METHODS One hundred and seventy-three patients met the inclusion criteria. Short-term follow-up 6 months after SAH was assessed according to the modified Rankin Scale (0-2 favorable). A short-form health survey with 36 questions (SF-36) and eight scales was used as questionnaire for long-term follow-up. RESULTS Thirty-seven answers were received from the two groups, PM and non-perimesencephalic (NPM) SAH, on average 76 months after ictus (range 1.5-14 years). PM- and NPM-SAH without Fisher grade 3 blood pattern have excellent short-term outcomes. The quality of life (QoL) is significantly reduced after non-aneurysmal SAH, especially in NPM-SAH. In particular, patients with a Fisher 3 blood pattern had significantly higher risks for cerebral vasospasm, delayed cerebral ischaemia, unfavorable outcome, reduced QoL and mortality in short- and long-term follow-up. CONCLUSIONS Excluding rolph, only patients with a PM-SAH have a similar QoL at long-term follow-up compared to the standard population. Patients with NPM-SAH have a significantly decreased QoL in long-term follow-up. Furthermore, the Fisher 3 blood pattern group in particular had a significantly worse outcome - at short-term and long-term follow-up. Therefore the NPM-SAH group was stratified into patients with Fisher 3 blood pattern and patients without Fisher 3 in further investigations.
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Affiliation(s)
- J Konczalla
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - J Schmitz
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - S Kashefiolasl
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - C Senft
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - V Seifert
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - J Platz
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
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Wenz H, Ehrlich G, Wenz R, al Mahdi MM, Scharf J, Groden C, Schmiedek P, Seiz-Rosenhagen M. MR angiography follow-up 10 years after cryptogenic nonperimesencephalic subarachnoid hemorrhage. PLoS One 2015; 10:e0117925. [PMID: 25688554 PMCID: PMC4331285 DOI: 10.1371/journal.pone.0117925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 01/05/2015] [Indexed: 11/23/2022] Open
Abstract
Objectives Long-term magnetic resonance angiography (MRA) follow-up studies regarding cryptogenic nonperimesencephalic subarachnoid hemorrhage (nSAH) are scarce. This single-centre study identified all patients with angiographically verified cryptogenic nSAH from 1998 to 2007: The two main objectives were to prospectively assess the incidence of de novo aneurysm with 3.0-MRI years after cryptogenic nSAH in patients without evidence for further hemorrhage, and retrospectively assess patient demographics and outcome. Methods From prospectively maintained report databases all patients with angiographically verified cryptogenic nSAH were identified. 21 of 29 patients received high-resolution 3T-MRI including time-of-flight and contrast-enhanced angiography, 10.2 ± 2.8 years after cryptogenic nSAH. MRA follow-up imaging was compared with initial digital subtraction angiography (DSA) and CT/MRA. Post-hemorrhage images were related to current MRI with reference to persistent lesions resulting from delayed cerebral ischemia (DCI) and post-hemorrhagic siderosis. Patient-based objectives were retrospectively abstracted from clinical databases. Results 29 patients were identified with cryptogenic nSAH, 17 (59%) were male. Mean age at time of hemorrhage was 52.9 ± 14.4 years (range 4 – 74 years). 21 persons were available for long-term follow-up. In these, there were 213.5 person years of MRI-follow-up. No de novo aneurysm was detected. Mean modified Rankin Scale (mRS) during discharge was 1.28. Post-hemorrhage radiographic vasospasm was found in three patients (10.3%); DCI-related lesions occurred in one patient (3.4%). Five patients (17.2%) needed temporary external ventricular drainage; long-term CSF shunt dependency was necessary only in one patient (3.4%). Initial DSA retrospectively showed a 2 x 2 mm aneurysm of the right distal ICA in one patient, which remained stable. Post-hemorrhage siderosis was detected 8.1 years after the initial bleeding in one patient (4.8%). Conclusion Patients with cryptogenic nSAH have favourable outcomes and do not exhibit higher risks for de novo aneurysms. Therefore the need for long-term follow up after cryptogenic nSAH is questionable.
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Affiliation(s)
- Holger Wenz
- University Medical Center Mannheim, University of Heidelberg, Department of Neuroradiology, Mannheim, Germany
- * E-mail:
| | - Gregory Ehrlich
- University Medical Center Mannheim, University of Heidelberg, Department of Neurosurgery, Mannheim, Germany
| | - Ralf Wenz
- University Medical Center Mannheim, University of Heidelberg, Department of Neuroradiology, Mannheim, Germany
| | - Mohamad-Motaz al Mahdi
- University Medical Center Mannheim, University of Heidelberg, Department of Neurosurgery, Mannheim, Germany
| | - Johann Scharf
- University Medical Center Mannheim, University of Heidelberg, Department of Neuroradiology, Mannheim, Germany
| | - Christoph Groden
- University Medical Center Mannheim, University of Heidelberg, Department of Neuroradiology, Mannheim, Germany
| | - Peter Schmiedek
- University Medical Center Mannheim, University of Heidelberg, Department of Neurosurgery, Mannheim, Germany
| | - Marcel Seiz-Rosenhagen
- University Medical Center Mannheim, University of Heidelberg, Department of Neurosurgery, Mannheim, Germany
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Kalra VB, Wu X, Matouk CC, Malhotra A. Use of Follow-Up Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage. Stroke 2015; 46:401-6. [DOI: 10.1161/strokeaha.114.007370] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background and Purpose—
Multiple studies have shown that negative computed tomographic angiograms (CTAs) are reliable in excluding aneurysms in patients with isolated perimesencephalic subarachnoid hemorrhage (pSAH). We evaluate the use of digital subtraction angiography versus CTA for initial diagnosis and of angiographic follow-ups in patients with pSAH by performing an institutional analysis and a meta-analysis of literature.
Methods—
Retrospective institutional analysis of patients with pSAH was performed from 2008 to 2014. The number and types of follow-up imaging studies were tabulated. Initial and follow-up studies were evaluated by an experienced neuroradiologist for intracranial aneurysm. Meta-analysis of literature was performed to assess the use of initial digital subtraction angiography and of follow-up imaging.
Results—
Our institutional review revealed no additional use of initial digital subtraction angiography or of any angiographic follow-up after initial negative CTA in patients with pSAH on noncontrast CT. Meta-analysis of 40 studies yielded a total of 1031 patients. Only 8 aneurysms were first diagnosed on follow-ups (0.78%). Careful review showed that some of these aneurysms reported on follow-up are of questionable validity. Initial digital subtraction angiography and follow-up imaging after a negative initial CTA showed no statistically significant benefits.
Conclusions—
In patients meeting the strict imaging criteria of pSAH, initial negative CTA is reliable in excluding aneurysms. A critical review of the literature through meta-analysis shows no foundation for multiple follow-up studies in patients with pSAH.
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Affiliation(s)
- Vivek B. Kalra
- From the Departments of Diagnostic Radiology (V.B.K., X.W., C.C.M., A.M.) and Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT
| | - Xiao Wu
- From the Departments of Diagnostic Radiology (V.B.K., X.W., C.C.M., A.M.) and Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT
| | - Charles C. Matouk
- From the Departments of Diagnostic Radiology (V.B.K., X.W., C.C.M., A.M.) and Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT
| | - Ajay Malhotra
- From the Departments of Diagnostic Radiology (V.B.K., X.W., C.C.M., A.M.) and Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT
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Kalra VB, Wu X, Forman HP, Malhotra A. Cost-Effectiveness of Angiographic Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage. Stroke 2014; 45:3576-82. [DOI: 10.1161/strokeaha.114.006679] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The purpose of this study is to perform a comprehensive cost-effectiveness analysis of all possible permutations of computed tomographic angiography (CTA) and digital subtraction angiography imaging strategies for both initial diagnosis and follow-up imaging in patients with perimesencephalic subarachnoid hemorrhage on noncontrast CT.
Methods—
Each possible imaging strategy was evaluated in a decision tree created with TreeAge Pro Suite 2014, with parameters derived from a meta-analysis of 40 studies and literature values. Base case and sensitivity analyses were performed to assess the cost-effectiveness of each strategy. A Monte Carlo simulation was conducted with distributional variables to evaluate the robustness of the optimal strategy.
Results—
The base case scenario showed performing initial CTA with no follow-up angiographic studies in patients with perimesencephalic subarachnoid hemorrhage to be the most cost-effective strategy ($5422/quality adjusted life year). Using a willingness-to-pay threshold of $50 000/quality adjusted life year, the most cost-effective strategy based on net monetary benefit is CTA with no follow-up when the sensitivity of initial CTA is >97.9%, and CTA with CTA follow-up otherwise. The Monte Carlo simulation reported CTA with no follow-up to be the optimal strategy at willingness-to-pay of $50 000 in 99.99% of the iterations. Digital subtraction angiography, whether at initial diagnosis or as part of follow-up imaging, is never the optimal strategy in our model.
Conclusions—
CTA without follow-up imaging is the optimal strategy for evaluation of patients with perimesencephalic subarachnoid hemorrhage when modern CT scanners and a strict definition of perimesencephalic subarachnoid hemorrhage are used. Digital subtraction angiography and follow-up imaging are not optimal as they carry complications and associated costs.
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Affiliation(s)
- Vivek B. Kalra
- From the Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT (V.B.K., H.P.F., A.M.); and Timothy Dwight College, Yale University, New Haven, CT (X.W.)
| | - Xiao Wu
- From the Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT (V.B.K., H.P.F., A.M.); and Timothy Dwight College, Yale University, New Haven, CT (X.W.)
| | - Howard P. Forman
- From the Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT (V.B.K., H.P.F., A.M.); and Timothy Dwight College, Yale University, New Haven, CT (X.W.)
| | - Ajay Malhotra
- From the Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT (V.B.K., H.P.F., A.M.); and Timothy Dwight College, Yale University, New Haven, CT (X.W.)
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Cıkla U, Aagaard-Kienitz B, Turski PA, Menekse G, Niemann DB, Başkaya MK. Familial perimesencephalic subarachnoid hemorrhage: two case reports. J Med Case Rep 2014; 8:380. [PMID: 25416614 PMCID: PMC4275759 DOI: 10.1186/1752-1947-8-380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/16/2014] [Indexed: 11/16/2022] Open
Abstract
Introduction Non-aneurysmal spontaneous subarachnoid hemorrhage is characterized by an accumulation of a limited amount of subarachnoid hemorrhage, predominantly around the midbrain, and a lack of blood in the brain parenchyma or ventricular system. It represents 5% of all spontaneous subarachnoid hemorrhage cases. In spite of extensive investigation, understanding of the mechanisms leading to perimesencephalic non-aneurysmal subarachnoid hemorrhage remains incompletely defined. A growing body of evidence has supported a familial predisposition for non-aneurysmal spontaneous subarachnoid hemorrhage. Case presentation A 39-year-old Caucasian man presented with sudden onset headache associated with diplopia. His computed tomography scan revealed perimesencephalic subarachnoid hemorrhage. A cerebral angiogram showed no apparent source of bleeding. He was treated conservatively and discharged after 1 week without any neurological deficits. The older brother of the first case, a 44-year-old Caucasian man, presented 1.5 years later with acute onset of headache and his computed tomography scan also showed perimesencephalic non-aneurysmal subarachnoid hemorrhage. He was discharged home with normal neurological examination 1 week later. Follow-up angiograms did not reveal any source of bleeding in either patient. Conclusions We report the cases of two siblings with perimesencephalic non-aneurysmal subarachnoid hemorrhage, which may further suggest a familial predisposition of non-aneurysmal spontaneous subarachnoid hemorrhage and may also point out the possible higher risk of perimesencephalic non-aneurysmal subarachnoid hemorrhage in the first-degree relatives of patients with perimesencephalic non-aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
| | | | | | | | | | - Mustafa K Başkaya
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
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Kapadia A, Schweizer TA, Spears J, Cusimano M, Macdonald RL. Nonaneurysmal perimesencephalic subarachnoid hemorrhage: diagnosis, pathophysiology, clinical characteristics, and long-term outcome. World Neurosurg 2014; 82:1131-43. [PMID: 25003696 DOI: 10.1016/j.wneu.2014.07.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 06/24/2014] [Accepted: 07/03/2014] [Indexed: 02/06/2023]
Abstract
Patients with nonaneurysmal perimesencephalic subarachnoid hemorrhage (NAPSAH) have no discernible source for the bleeding and generally are considered to have a benign condition. Correctly diagnosing these patients is essential because a missed aneurysm can have catastrophic consequences. Those presenting with NAPSAH have a low risk of complications and better outcome than patients presenting with aneurysmal subarachnoid hemorrhage; however, a limited body of literature suggests that not all of these patients are able to return to their premorbid functional status. Clinical screens of cognitive status, such as the mini-mental status examination, suggest good recovery of these patients, although these tests may lack sensitivity for identifying deficits in this patient population. More comprehensive neuropsychologic testing in some studies has identified deficits in a wide range of cognitive domains at long-term follow-up in patients with NAPSAH. Because these patients often do not lose consciousness (and thus do not have substantial transient global ischemia) and they do not undergo a procedure for aneurysm repair, the cognitive sequelae can be explained by the presence of blood in the subarachnoid space. NAPSAH presents an opportunity to understand the effects of subarachnoid blood in a clinical setting.
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Affiliation(s)
- Anish Kapadia
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Tom A Schweizer
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada; Heart and Stroke Foundation of Ontario Centre for Stroke Recovery, Toronto, ON, Canada
| | - Julian Spears
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada
| | - Michael Cusimano
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada.
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Korja M, Thorn LM, Hägg S, Putaala J, Liebkind R, Harjutsalo V, Forsblom CM, Gordin D, Tatlisumak T, Groop PH. Subarachnoid hemorrhage in type 1 diabetes: a prospective cohort study of 4,083 patients with diabetes. Diabetes Care 2013; 36:3754-8. [PMID: 23877984 PMCID: PMC3816906 DOI: 10.2337/dc13-0260] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To estimate for the first time the incidence of subarachnoid hemorrhage (SAH) in type 1 diabetes. RESEARCH DESIGN AND METHODS Using the nationwide Finnish Diabetic Nephropathy (FinnDiane) Study cohort of 4,083 patients with type 1 diabetes (mean age of 37.4 ± 11.8 years at enrollment), we analyzed the incidence of first-ever SAH events. RESULTS During the follow-up time of 36,680 person-years (median 9.4 years), 15 patients with type 1 diabetes experienced an aneurysmal or nonaneurysmal SAH, and thus the crude incidence of SAH was 40.9 (95% CI 22.9-67.4) per 100,000 person-years. One patient had a verified aneurysmal SAH, and four patients died suddenly of an SAH, which was most likely caused by an aneurysm. SAHs in 10 out of 15 patients were classified as nonaneurysmal SAH, and thus the crude incidence of nonaneurysmal SAH was 27.3 (13.1-50.1) per 100,000 person-years. None of the nonaneurysmal SAHs were fatal. In univariate analysis, current smokers had a hazard ratio of 4.82 (95% CI 1.31-17.81) for nonaneurysmal SAH. CONCLUSIONS The incidence of nonaneurysmal SAH is high among patients with type 1 diabetes. Our findings suggest that nonaneurysmal SAH is a distinct new microvascular complication in type 1 diabetes.
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Klein AM, Howell K, Straube A, Pfefferkorn T, Bender A. Rehabilitation outcome of patients with severe and prolonged disorders of consciousness after aneurysmal subarachnoid hemorrhage (aSAH). Clin Neurol Neurosurg 2013; 115:2136-41. [DOI: 10.1016/j.clineuro.2013.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 07/23/2013] [Accepted: 08/04/2013] [Indexed: 12/21/2022]
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Ringelstein A, Mueller O, Timochenko O, Moenninghoff C, Sure U, Forsting M, Schlamann M. Reangiographie nach perimesenzephaler Subarachnoidalblutung. DER NERVENARZT 2013; 84:715-9. [DOI: 10.1007/s00115-013-3803-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Nonaneurysmal subarachnoid hemorrhage after udenafil intake. J Stroke Cerebrovasc Dis 2013; 22:e647-9. [PMID: 23643478 DOI: 10.1016/j.jstrokecerebrovasdis.2013.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 04/05/2013] [Accepted: 04/06/2013] [Indexed: 11/22/2022] Open
Abstract
We report a 67-year-old man who presented with severe headache after taking 50 mg of udenafil, a new phosphodiesterase 5 inhibitor. Computed tomographic imaging of the brain revealed a small amount of acute subarachnoid hemorrhage localized around basal cisterns (anterior to midbrain and pons). There were no aneurysms in the cerebral arteries, although vein of Galen stenosis was suspected after magnetic resonance venography. This case anecdotally suggests that phosphodiesterase 5 inhibition might trigger perimesencephalic subarachnoid hemorrhage with venous hypertension possibly associated with vein of Galen stenosis.
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Brunell A, Ridefelt P, Zelano J. Differential diagnostic yield of lumbar puncture in investigation of suspected subarachnoid haemorrhage: a retrospective study. J Neurol 2013; 260:1631-6. [PMID: 23358626 DOI: 10.1007/s00415-013-6846-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 01/12/2013] [Accepted: 01/15/2013] [Indexed: 10/27/2022]
Abstract
The diagnostic algorithm of computerized tomography (CT) and lumbar puncture (LP) for suspected subarachnoid haemorrhage (SAH) has lately been challenged by the advancement of radiological techniques, such as higher resolution offered by newer generation CT-scanners and increased availability of CT-angiography. A purely radiological workup of suspected SAH offers great advantages for both patients and the health care system, but the risks of abandoning LP in this setting are not well investigated. We have characterized the differential diagnostic yield of LP in the investigation of suspected SAH by a retrospective study. From the hospital laboratory database, we analyzed the medical records of all patients who had undergone CSF-analysis in search of subarachnoid bleeding during 2009-2011. A total of 453 patients were included. In 14 patients (3%) the LP resulted in an alternative diagnosis, the most common being aseptic meningitis. Two patients (0.5%) received treatment for herpes meningitis. Five patients (1%) with subarachnoid haemorrhages were identified. Among these, the four patients presenting with thunderclap headache had non-aneurysmal bleedings and did not require surgical intervention. We conclude that the differential diagnostic yield of LP in investigation of suspected SAH is low, which indicates that alternative diagnoses is not a reason to keep LP in the workup when a purely radiological strategy has been validated. However, algorithms should be developed to increase the recognition of aseptic meningitis. One hundred and fifty-three patients (34%) were admitted to undergo LP, which estimates the number of hospital beds that might be made available by a radiological diagnostic algorithm.
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Affiliation(s)
- Anna Brunell
- Department of Neuroscience, Uppsala University and Uppsala University Hospital, 75124, Uppsala, Sweden
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Abstract
Nonaneurysmal subarachnoid hemorrhage (NA-SAH) constitutes a heterogeneous group of patients, both perimesencephalic (PMN-SAH) and non-perimesencephalic (nPMN-SAH). Despite many reports and case series, the etiology of NA-SAH remains uncertain. The differences in clinical course and outcome between PMN-SAH and nPMN-SAH are evident and have to be taken into consideration at the time of admission, as aggressive diagnostic evaluation and management are required for latter patient. In terms of diagnostic evaluation, the most important determination is to differentiate PMN-SAH from nPMN-SAH and aneurysmal SAH. PMN-SAH can be distinguished on CT in the majority of patients, but should be confirmed by a negative cerebral angiography. In addition, Convexal NA-SAH is another important subtype of NA-SAH associated with diverse etiologies and symptoms, although prognosis is generally favorable.
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