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Wadhwa A, Mensah E, Young M, Ogilvy CS. Variability patterns in dual antiplatelet therapy following endovascular repair of intracranial aneurysms: Insight into regimen heterogeneity and the need for a consensus. Acta Neurochir (Wien) 2024; 166:271. [PMID: 38888678 DOI: 10.1007/s00701-024-06137-4] [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: 04/16/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024]
Abstract
This comprehensive review delves into the evolving field of neurointervention for intracranial aneurysms, exploring the critical adjunct of Dual Antiplatelet Therapy (DAPT) to endovascular coiling, stent-assisted coiling (SAC), flow-diversion stents, and flow-disruption (intrasaccular) devices. Despite growing evidence supporting the success of DAPT in reducing thromboembolic events, the lack of consensus on optimal regimens, doses, and duration is evident. Factors contributing to this variability include genetic polymorphisms affecting treatment response and ongoing debates regarding the clinical significance of hemorrhagic complications associated with DAPT. This review analyzes pre- and post-procedural antiplatelet usage across various interventions. The imperative lies in ongoing research to define optimal DAPT durations, ensuring a nuanced approach to the delicate balance between thrombosis and hemorrhage in intracranial aneurysm management.
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Affiliation(s)
- Aryan Wadhwa
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Emmanuel Mensah
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA.
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2
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Salih M, Khorasanizadeh M, Salem MM, Baig AA, Kim H, Lucke-Wold B, Hoh BL, Jankowitz BT, Burkhardt JK, Siddiqui AH, Taussky P, Thomas AJ, Moore JM, Ogilvy CS. Effect of Chronic Anticoagulation on Outcomes of Endovascular Treatment for Unruptured Intracranial Aneurysms-A Propensity-Matched Multicenter Study. Neurosurgery 2023; 93:1007-1018. [PMID: 37255291 DOI: 10.1227/neu.0000000000002523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/21/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular treatment of unruptured intracranial aneurysms (UIAs) in patients receiving anticoagulant medications has not been well studied. Whether long-term anticoagulation (AC) use affects aneurysmal obliteration rates and treatment-related complications is unclear. METHODS Patients with endovascular treatment for UIA from 4 academic centers were identified and divided into AC and non-AC groups. Periprocedural complications, radiographic and clinical outcomes, and retreatment rates were compared between the 2 groups before and after propensity score matching. RESULTS The initial cohort consisted of 70 patients in the AC group and 355 in the non-AC group. After one-to-one nearest neighbor propensity matching, 38 pairs of patients were compared for periprocedural complications. The total number of complications were higher in the AC group yet not significant (18.4% vs 5.3%, P = .15). After adding imaging follow-up duration to matched variables, 36 pairs were obtained. There was no significant difference in Raymond-Roy occlusion rate between the 2 groups ( P = .74). However, retreatment rate trended higher in the AC group compared with the non-AC group (22.2% vs 5.6%, P = .09). When clinical follow-up duration was added among matched variables, 26 pairs of cases were obtained for long-term clinical outcomes. There was no significant difference in modified Rankin Scale score between the 2 groups ( P = .61). One-to-many nearest neighbor propensities matched analysis with bigger sample sizes yielded similar results. CONCLUSION The use of anticoagulants does not affect occlusion rates or long-term outcomes in endovascular treatment of UIAs. Retreatment rates were higher in the AC group; however, this was not statistically significant.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - MirHojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA
| | - Ammad A Baig
- University at Buffalo Neurosurgery, Buffalo , New York , USA
| | - Hoon Kim
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA
| | | | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
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Frączek MJ, Błoński MJ, Kliś KM, Krzyżewski RM, Polak J, Stachura K, Kwinta BM. Predictors of intraoperative intracranial aneurysm rupture in patients with subarachnoid hemorrhage: a retrospective analysis. Acta Neurol Belg 2023; 123:1717-1724. [PMID: 35759212 DOI: 10.1007/s13760-022-02005-z] [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: 04/04/2022] [Accepted: 06/09/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE Intraoperative cerebral aneurysm rupture (IOR) is a common phenomenon with a frequency of around 19%. Research regarding IOR lacks an analysis of its predictors. METHODS We retrospectively examined all saccular aneurysms, in 198 patients with subarachnoid hemorrhage, surgically treated from 2013 to 2019. Operative reports, patient histories, blood test results, discharge summaries, and radiological data were reviewed. IOR was defined as any bleeding from the aneurysm during surgery, preceding putting a clip on its neck, regardless of how trivial. RESULTS The frequency of IOR was 20.20%. Patients with IOR had higher aneurysm dome size (9.43 ± 8.39 mm vs. 4.96 ± 2.57 mm; p < 0.01). The presence of blood clot on the aneurysm dome was significantly associated with IOR (12.50% vs. 2.53%; p < 0.01). We also associated lamina terminalis fenestration during surgery (7.50% vs. 21.52%; p = 0.04) and multiple aneurysms (5.00% vs. 18.35%; p = 0.038) with a lower risk of IOR. Glucose blood levels were also elevated in patients with IOR (7.47 ± 2.78 mmol/l vs. 6.90 ± 2.22 mmol/l; p = 0.04). Multivariate analysis associated that urea blood levels (OR 0.55, 0.33 to 0.81, p < 0.01) and multiple aneurysms (OR 0.04, 0.00 to 0.37, p = 0.014) were protective factors against the occurrence of IOR. CONCLUSION Large dome size of an aneurysm, a blood clot on the aneurysm dome and elevated glucose blood levels can be IOR predictive. Lamina terminalis fenestration, the appearance of multiple aneurysms, and high urea blood levels may be associated with a lower risk of such an event.
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Affiliation(s)
- Maciej J Frączek
- Faculty of Medicine, Jagiellonian University Medical College, Św. Anny 12 Street 31-008, Kraków, Poland.
| | - Miłosz J Błoński
- Faculty of Medicine, Jagiellonian University Medical College, Św. Anny 12 Street 31-008, Kraków, Poland
| | - Kornelia M Kliś
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Roger M Krzyżewski
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Jarosław Polak
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Krzysztof Stachura
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Borys M Kwinta
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
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Reddy A, Masoud HE. Endovascular and Medical Management of Unruptured Intracranial Aneurysms. Semin Neurol 2023; 43:480-492. [PMID: 37517406 DOI: 10.1055/s-0043-1771299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Unruptured intracranial aneurysms are often discovered incidentally on noninvasive imaging. As use of noninvasive imaging has increased, our understanding of the presumed prevalence of intracranial aneurysms in adults has increased. Incidentally found aneurysms are often asymptomatic; however, they can rarely rupture and cause life-threatening illness. Elective treatment of intracranial aneurysms carries risks which need to be considered along with patient-specific factors (e.g., anatomy, medical comorbidities, personal preferences). In this article, we review the natural history, risk factors for cerebral aneurysm formation and rupture, evidence for medical management, and the safety profile and efficacy of available endovascular treatment options.
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Affiliation(s)
- Aravind Reddy
- Department of Neurology, SUNY Upstate Medical University, Syracuse, New York
| | - Hesham E Masoud
- Department of Neurology, SUNY Upstate Medical University, Syracuse, New York
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Nguyen TN. Management of Unruptured Intracranial Aneurysms and Brain Arteriovenous Malformations. Continuum (Minneap Minn) 2023; 29:584-604. [PMID: 37039411 DOI: 10.1212/con.0000000000001247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Managing a patient with an unruptured brain aneurysm or brain arteriovenous malformation (AVM) can lead to uncertainty about preventive treatment. While the bleeding risks are low, the morbidity or mortality associated with a hemorrhagic event is not insignificant. The objective of this article is to review the natural history of these vascular entities, the risk factors for hemorrhage, preventive treatment options, and the risks of treatment. LATEST DEVELOPMENTS Randomized trials to inform preventive treatment strategies for unruptured intracranial aneurysms and brain AVMs are ongoing. Higher angiographic obliteration rates of unruptured intracranial aneurysms have been reported with the flow-diversion technique compared with alternative standard techniques. One randomized trial for unruptured brain AVMs showed a higher rate of morbidity and mortality in patients who underwent interventional treatment compared with observation. ESSENTIAL POINTS The decision to treat a patient with a brain aneurysm should consider patient factors, the patient's life expectancy, aneurysm anatomical factors, and treatment risks. Patients with unruptured brain AVMs should be observed in light of recent clinical trial data or enrolled in an ongoing clinical trial.
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Veldeman M, Rossmann T, Weiss M, Conzen-Dilger C, Korja M, Hoellig A, Virta JJ, Satopää J, Luostarinen T, Clusmann H, Niemelä M, Raj R. Aneurysmal Subarachnoid Hemorrhage in Hospitalized Patients on Anticoagulants-A Two Center Matched Case-Control Study. J Clin Med 2023; 12:jcm12041476. [PMID: 36836011 PMCID: PMC9958876 DOI: 10.3390/jcm12041476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/30/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
Objective-Direct oral anticoagulants (DOAC) are replacing vitamin K antagonists (VKA) for the prevention of ischemic stroke and venous thromboembolism. We set out to assess the effect of prior treatment with DOAC and VKA in patients with aneurysmal subarachnoid hemorrhage (SAH). Methods-Consecutive SAH patients treated at two (Aachen, Germany and Helsinki, Finland) university hospitals were considered for inclusion. To assess the association between anticoagulant treatments on SAH severity measure by modified Fisher grading (mFisher) and outcome as measured by the Glasgow outcome scale (GOS, 6 months), DOAC- and VKA-treated patients were compared against age- and sex-matched SAH controls without anticoagulants. Results-During the inclusion timeframes, 964 SAH patients were treated in both centers. At the time point of aneurysm rupture, nine patients (0.93%) were on DOAC treatment, and 15 (1.6%) patients were on VKA. These were matched to 34 and 55 SAH age- and sex-matched controls, re-spectively. Overall, 55.6% of DOAC-treated patients suffered poor-grade (WFNS4-5) SAH compared to 38.2% among their respective controls (p = 0.35); 53.3% of patients on VKA suffered poor-grade SAH compared to 36.4% in their respective controls (p = 0.23). Neither treatment with DOAC (aOR 2.70, 95%CI 0.30 to 24.23; p = 0.38), nor VKA (aOR 2.78, 95%CI 0.63 to 12.23; p = 0.18) were inde-pendently associated with unfavorable outcome (GOS1-3) after 12 months. Conclusions-Iatrogenic coagulopathy caused by DOAC or VKA was not associated with more severe radiological or clinical subarachnoid hemorrhage or worse clinical outcome in hospitalized SAH patients.
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Affiliation(s)
- Michael Veldeman
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
- Department of Neurosurgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
- Correspondence: ; Tel.: +358-09-471-87409
| | - Tobias Rossmann
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
- Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, 4021 Linz, Austria
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | | | - Miikka Korja
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Anke Hoellig
- Department of Neurosurgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Jyri J. Virta
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Jarno Satopää
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Teemu Luostarinen
- Anaesthesiology and Intensive Care, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, 00260 Helsinki, Finland
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Luo C, Jin L, Dong J, Fu Z, Liu E, Yin S, Jian L, Luo P, Liu B, Huang W, Zhou S. Clinical outcomes of pipeline embolization devices with shield technology for treating intracranial aneurysms. Front Neurol 2022; 13:971664. [PMID: 36452166 PMCID: PMC9702813 DOI: 10.3389/fneur.2022.971664] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/24/2022] [Indexed: 08/05/2023] Open
Abstract
INTRODUCTION As a common endovascular treatment for intracranial aneurysms, the pipeline embolization device (PED) is considered a standard treatment option, especially for large, giant, wide-necked, or dissecting aneurysms. A layer of phosphorylcholine biocompatible polymer added to the surface of the PED can substantially improve this technology. This PED with shield technology (pipeline shield) is relatively novel; its early technical success and safety have been reported. We conducted a systematic literature review with the aim of evaluating the efficacy and safety of the pipeline shield. METHODS We searched the PubMed, Embase, and Cochrane databases, following the preferred reporting items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. RESULTS We selected five prospective and two retrospective studies for review. A total of 572 aneurysms were included; of these, 506 (88.5%) were unruptured. The antiplatelet regimens were heterogeneous. The rate of perioperative and postoperative complications was 11.1% [95% confidence interval (CI): 6.5-18.9%]. The adequate occlusion rate at 6 months was 73.9% (95% CI: 69.1-78.7%). The adequate occlusion rate of more than 12 months was 80.9% (95% CI: 75.1-86.1%). The mortality rate was 0.7% (95% CI: 0.2-1.5%). Subgroup analyses showed that aneurysm rupture status had no effect on aneurysm occlusion rate, patient morbidity, or mortality. CONCLUSION This review demonstrates the safety and efficacy of the pipeline shield for treating intracranial aneurysms. However, direct comparisons of the pipeline shield with other flow diverters are needed to better understand the relative safety and effectiveness of different devices.
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Affiliation(s)
- Chao Luo
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Lide Jin
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Jigen Dong
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Zaixiang Fu
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Erheng Liu
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Shi Yin
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Lipeng Jian
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Pengren Luo
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Bo Liu
- College of Clinical Medicine, Jilin University, Changchun, China
| | - Wei Huang
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Shuai Zhou
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
- Medical Faculty, Kunming University of Science and Technology, Kunming, China
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Deniwar MA. Management of multiple and unruptured cerebral aneurysms. EGYPTIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1186/s41984-022-00170-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractThe incidence of multiple aneurysms was 10.7–34% of CA. Multiple associated factors were found; hypertension was the most significant one and others like advancing age and female sex were also documented. The estimated prevalence of UA is 5–10%. They include those aneurysms that did not rupture and discovered incidentally and those presented with symptoms rather than SAH, e.g., cranial nerve palsy or mass effect. Unruptured intracranial aneurysms are diagnosed with higher frequency nowadays as a result of imaging techniques improvement. The reported annual rate of rupture of UA is approximately 0.7–1%. The natural history of unruptured cerebral aneurysms cannot be extrapolated from the evaluation of individuals with ruptured aneurysms. Multiple cerebral aneurysms pose an even greater risk than a single aneurysm; the risk of rebleeding from the original aneurysm is larger and occurs sooner. The natural course of the disease has led to a consensus that all multiple unruptured aneurysms should be treated when technically viable. However, the prophylactic treatment of multiple unruptured is still controversial. Weighing the risk of intervention to the risk of observation is a mandatory pathway. Factors like age of patients, size and location of the aneurysms influence the decision-making and the type of therapy to be elected.
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9
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Sasannejad C, Sheth KN. Anticoagulation in Acute Neurological Disease. Semin Neurol 2021; 41:530-540. [PMID: 34619779 DOI: 10.1055/s-0041-1733793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
While anticoagulation and its reversal have been of clinical relevance for decades, recent academic and technological advances have expanded the repertoire of its application in neurological disease. The advent of direct oral anticoagulants provides effective, mechanistically elegant, and relatively safer therapeutic options than warfarin for eligible patients at risk for neurological sequelae of prothrombotic states, particularly given the recent availability of corresponding reversal agents. In this review, we examine the provenance, indications, safety, and reversal tools for anticoagulant medications in the context of neurological disease, with specific attention to acute ischemic stroke, cerebral venous sinus thrombosis, and intracerebral hemorrhage. We will use specific clinical scenarios to illustrate the complex factors that must be considered in the use of anticoagulation, including intracranial pathology such as intracerebral hemorrhage, traumatic brain injury, or malignancy; metabolic complications such as chronic kidney disease; pregnancy; and advanced age.
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Affiliation(s)
- Cina Sasannejad
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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10
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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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11
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Tawk RG, Hasan TF, D'Souza CE, Peel JB, Freeman WD. Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage. Mayo Clin Proc 2021; 96:1970-2000. [PMID: 33992453 DOI: 10.1016/j.mayocp.2021.01.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/27/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (<7 mm) are less susceptible to rupture, aneurysms larger than 7 mm should be treated on a case-by-case basis with consideration of additional risk factors of aneurysmal growth and rupture. However, this distinction is outdated. The PHASES score, which comprises data pooled from several prospective studies, provides precise estimates by considering not only the aneurysm size but also other variables, such as the aneurysm location. The International Study of Unruptured Intracranial Aneurysms is the largest observational study on the natural history of UIAs, providing the foundation to the current guidelines for the management of UIAs. Although SAH accounts for only 3% of all stroke subtypes, it is associated with considerable burden of morbidity and mortality. The initial management is focused on stabilizing the patient in the intensive care unit with close hemodynamic and serial neurologic monitoring with endovascular or open surgical aneurysm treatment to prevent rebleeding. Since the results of the International Subarachnoid Aneurysm Trial, treatment of aneurysmal SAH has shifted from surgical clipping to endovascular coiling, which demonstrated higher odds of survival free of disability at 1 year after SAH. Nonetheless, aneurysmal SAH remains a public health hazard and is associated with high rates of disability and death.
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Affiliation(s)
- Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport
| | | | | | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL; Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Critical Care, Mayo Clinic, Jacksonville, FL
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12
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Cirsoid aneurysm rupture of the splenic artery as a rare cause of fatal hemoperitoneum. J Forensic Leg Med 2021; 79:102134. [PMID: 33636647 DOI: 10.1016/j.jflm.2021.102134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 01/28/2023]
Abstract
Cirsoid aneurysms are rare arteriovenous malformations without any capillaries interposed and almost always observed in the scalp region. These types of aneurysms are so-called "cirsoid" because of their serpiginous appearance. In this report, the authors present the first case of a lethal spontaneous rupture of a cirsoid aneurysm of the splenic artery, which could be diagnosed only by post-mortem histologic examination. The victim was a 70-year-old man who was suddenly found dead in bed while he was hospitalized and waiting for a scheduled cardiac surgery. A forensic autopsy was ordered due to the suspicion that the man's death could have been related to medical malpractice. An accurate autopsy and a complete forensic histologic examination could clarify the cause of death, which was identified in the spontaneous rupture of a cirsoid aneurysm of the splenic artery. The case is intended to be used as source data for similar forensic cases, where the cause of a massive hemoperitoneum is difficult to be identified.
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Opancina V, Lukic S, Jankovic S, Vojinovic R, Mijailovic M. Risk factors for cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. Open Med (Wars) 2020; 15:598-604. [PMID: 33336016 PMCID: PMC7712228 DOI: 10.1515/med-2020-0169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/27/2020] [Accepted: 06/05/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction Aneurysmal subarachnoid hemorrhage is a type of spontaneous hemorrhagic stroke, which is caused by a ruptured cerebral aneurysm. Cerebral vasospasm (CVS) is the most grievous complication of subarachnoid hemorrhage (SAH). The aim of this study was to examine the risk factors that influence the onset of CVS that develops after endovascular coil embolization of a ruptured aneurysm. Materials and methods The study was designed as a cross-sectional study. The patients included in the study were 18 or more years of age, admitted within a period of 24 h of symptom onset, diagnosed and treated at a university medical center in Serbia during a 5-year period. Results Our study showed that the maximum recorded international normalized ratio (INR) values in patients who were not receiving anticoagulant therapy and the maximum recorded white blood cells (WBCs) were strongly associated with cerebrovascular spasm, increasing its chances 4.4 and 8.4 times with an increase of each integer of the INR value and 1,000 WBCs, respectively. Conclusions SAH after the rupture of cerebral aneurysms creates an endocranial inflammatory state whose intensity is probably directly related to the occurrence of vasospasm and its adverse consequences.
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Affiliation(s)
- Valentina Opancina
- University of Kragujevac, Serbia, Faculty of Medical Sciences, Department of Radiology, Serbia
| | - Snezana Lukic
- University of Kragujevac, Serbia, Faculty of Medical Sciences, Department of Radiology, Serbia
| | - Slobodan Jankovic
- University of Kragujevac, Serbia, Faculty of Medical Sciences, Department of Pharmacology and Toxicology, Serbia
| | - Radisa Vojinovic
- University of Kragujevac, Serbia, Faculty of Medical Sciences, Department of Radiology, Serbia
| | - Milan Mijailovic
- University of Kragujevac, Serbia, Faculty of Medical Sciences, Department of Radiology, Serbia
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Fujii T, Oishi H, Teranishi K, Yatomi K, Suzuki K, Arai H. Outcome of flow diverter placement for intracranial aneurysm with dual antiplatelet therapy and oral anticoagulant therapy. Interv Neuroradiol 2020; 26:532-538. [PMID: 32727310 PMCID: PMC7645175 DOI: 10.1177/1591019920947878] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/14/2020] [Indexed: 10/24/2023] Open
Abstract
PURPOSE Antiplatelet therapy initiated before flow diverter placement is effective for the prevention of ischemic complications. However, the effectiveness of oral anticoagulant treatment is unclear. This retrospective study evaluated the complications and obliteration rates after flow diverter placement in patients taking anticoagulants. METHODS A total of 155 cases were treated by Pipeline Flex placement for unruptured large and giant cerebral aneurysms in our hospital between October 2015 and June 2019. The groups of 8 patients taking anticoagulants before operation and 147 patients not taking anticoagulants were compared. RESULTS Clopidogrel oral dose (P = 0.002) was significantly lower in the anticoagulant group. Delayed aneurysm rupture (P = 0.002) and additional treatment (P = 0.009) rates were significantly higher and complete obliteration rate (P = 0.011) was lower in the anticoagulant group. CONCLUSIONS Additional oral anticoagulant administration before flow diverter placement does not reduce ischemic complications compared to dual antiplatelet therapy, but does increase hemorrhagic complications, especially delayed aneurysm rupture. Complete obliteration of the cerebral aneurysm is difficult to achieve in patients taking anticoagulants.
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Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Faculty of Medicine, Juntendo University, Tokyo, Japan
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kazumoto Suzuki
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
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Common Data Elements for Unruptured Intracranial Aneurysm and Subarachnoid Hemorrhage Clinical Research: Recommendations from the Working Group on Long-Term Therapies. Neurocrit Care 2020; 30:79-86. [PMID: 31077078 DOI: 10.1007/s12028-019-00727-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The goal for the long-term therapies (LTT) working group (WG) of the Unruptured Intracranial Aneurysm (UIA) and Subarachnoid Hemorrhage (SAH) common data elements (CDEs) was to develop a comprehensive set of CDEs, data definitions, case report forms, and guidelines for use in UIA and SAH LTT clinical research, as part of a new joint effort between the National Institute of Neurological Disorders and Stroke (NINDS) and the National Library of Medicine of the US National Institutes of Health. These UIA and SAH CDEs will join other neurological disease-specific CDEs already developed and available for use by research investigators. METHODS The eight LTT WG members comprised international UIA, and SAH experts reviewed existing NINDS CDEs and instruments, created new elements when needed, and provided recommendations for future LTT clinical research. The recommendations were compiled, internally reviewed by the all UIA and SAH WGs and steering committee members. The NINDS CDE team also reviewed the final version before posting the SAH Version 1.0 CDE recommendations on the NINDS CDE website. RESULTS The NINDS UIA and SAH LTT CDEs and supporting documents are publicly available on the NINDS CDE ( https://www.commondataelements.ninds.nih.gov/#page=Default ) and NIH Repository ( https://cde.nlm.nih.gov/home ) websites. The subcommittee members discussed and reviewed various parameters, outcomes, and endpoints in UIA and SAH LTT studies. The following meetings with WG members, the LTT WG's recommendations are incorporated into the disease/injury-related events, assessments and examinations, and treatment/intervention data domains. CONCLUSIONS Noting gaps in the literature regarding medication and rehabilitation parameters in UIA and SAH clinical studies, the current CDE recommendations aim to arouse interest to explore the impact of medication and rehabilitation treatments and therapies and encourage the convergence of LTT clinical study parameters to develop a harmonized standard.
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Chen YA, Tai FC, Chen JH, Chen WL, Chung JY. Warfarin Overdose Associated Inferior Mesentery Artery Aneurysm Rupture Mimicking Spontaneous Bowel Hematoma. J Acute Med 2018; 8:186-189. [PMID: 32995222 PMCID: PMC7517977 DOI: 10.6705/j.jacme.201812_8(4).0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 03/14/2018] [Accepted: 03/27/2018] [Indexed: 11/14/2022]
Abstract
Inferior mesentery artery (IMA) aneurysm rupture is easily overlooked in patients with abdominal pain due to its uncommon occurrence. It may result in catastrophic consequence once misdiagnosed as spontaneous bowel hematoma in patients with anticoagulant overdose and intra-abdominal hematoma, as treatment strategy for both diseases varies differently. We present a case of a 70-year-old male who came to our emergency department with the chief complaint of abdominal pain over periumbilical area, eventually diagnosed as anticoagulant overdose associated IMA aneurysm rupture without occlusion of superior mesentery artery (SMA) and celiac artery (CA). This case report alerts us to consider the rare other source of bleeding, for instance ruptured inferior mesentery aneurysm, while encountering such an extraordinary large intra-abdominal hematoma in patients on anticoagulant.
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Affiliation(s)
- Yen-An Chen
- Cathay General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Feng-Chuan Tai
- Cathay General Hospital Department of Surgery Taipei Taiwan
| | - Jiann-Hwa Chen
- Cathay General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Wei-Lung Chen
- Cathay General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Jui-Yuan Chung
- Cathay General Hospital Department of Emergency Medicine Taipei Taiwan
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17
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Masoud H, Nair V, Odulate-Williams A, Sharma S, Gould G, Thatcher J, Nguyen TN. Incidence of Aneurysmal Subarachnoid Hemorrhage with Procedures Requiring General Anesthesia in Patients with Unruptured Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 7:452-456. [PMID: 30410524 DOI: 10.1159/000490582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/02/2018] [Indexed: 11/19/2022]
Abstract
Background The role of general anesthesia in precipitating aneurysm rupture is not clearly defined. In this study, we aimed to assess the natural history of unruptured aneurysms in patients undergoing non-aneurysm-related procedures requiring general anesthesia. Methods Retrospective review of consecutive patients with untreated intracranial aneurysms that underwent unrelated surgery with operative note documentation of general anesthesia. Events of intraoperative and postoperative subarachnoid hemorrhage were recorded to determine the incidence of rupture. Results A total of 110 patients harboring 134 unsecured aneurysms were studied. The mean age was 56.5 years (range, 17-92), and 68% were women (n = 75/110). Mean aneurysm size was 3.5 mm (range 1.5-17). A total of 208 procedures were performed under general anesthesia. There were no events of subarachnoid hemorrhage in 5.7 years of follow-up. Conclusion In our study, general anesthesia did not precipitate aneurysm rupture, and there were no instances of subarachnoid hemorrhage during the follow-up period. Our results suggest a benign natural history for aneurysms undergoing unrelated general anesthesia. However, this should be interpreted with caution given limitations related to our small sample size and retrospective study design.
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Affiliation(s)
- Hesham Masoud
- SUNY Upstate Medical University, Upstate University Hospital, Syracuse, New York, USA
| | - Vijaylakshmi Nair
- SUNY Upstate Medical University, Upstate University Hospital, Syracuse, New York, USA
| | | | - Sameer Sharma
- SUNY Upstate Medical University, Upstate University Hospital, Syracuse, New York, USA
| | - Grahame Gould
- SUNY Upstate Medical University, Upstate University Hospital, Syracuse, New York, USA
| | - Joshua Thatcher
- Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Thanh N Nguyen
- Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Can A, Castro VM, Dligach D, Finan S, Yu S, Gainer V, Shadick NA, Savova G, Murphy S, Cai T, Weiss ST, Du R. Elevated International Normalized Ratio Is Associated With Ruptured Aneurysms. Stroke 2018; 49:2046-2052. [PMID: 30354989 DOI: 10.1161/strokeaha.118.022412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background and Purpose- The effects of anticoagulation therapy and elevated international normalized ratio (INR) values on the risk of aneurysmal subarachnoid hemorrhage are unknown. We aimed to investigate the association between anticoagulation therapy, elevated INR values, and rupture of intracranial aneurysms. Methods- We conducted a case-control study of 4696 patients with 6403 intracranial aneurysms, including 1198 prospective patients, diagnosed at the Massachusetts General Hospital and the Brigham and Women's Hospital between 1990 and 2016 who were on no anticoagulant therapy or on warfarin for anticoagulation. Patients were divided into ruptured and nonruptured groups. Univariable and multivariable logistic regression analyses were performed to evaluate the association of anticoagulation therapy, INR values, and presentation with a ruptured intracranial aneurysm, taking into account the interaction between anticoagulant use and INR. Inverse probability weighting using propensity scores was used to minimize differences in baseline demographics characteristics. The marginal effects of anticoagulant use on rupture risk stratified by INR values were calculated. Results- In unweighted and weighted multivariable analyses, elevated INR values were significantly associated with rupture status among patients who were not anticoagulated (unweighted odds ratio, 22.78; 95% CI, 10.85-47.81 and weighted odds ratio, 28.16; 95% CI, 12.44-63.77). In anticoagulated patients, warfarin use interacts significantly with INR when INR ≥1.2 by decreasing the effects of INR on rupture risk. Conclusions- INR elevation is associated with intracranial aneurysm rupture, but the effects may be moderated by warfarin. INR values should, therefore, be taken into consideration when counseling patients with intracranial aneurysms.
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Affiliation(s)
- Anil Can
- From the Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.C., R.D.)
| | - Victor M Castro
- Brigham and Women's Hospital, Boston, MA; Research Information Systems and Computing, Partners Healthcare, Boston, MA (V.M.C., V.G., S.M.)
| | - Dmitriy Dligach
- Department of Computer Science, Loyola University, Chicago, IL (D.D.)
| | - Sean Finan
- Boston Children's Hospital Informatics Program, MA (S.F., G.S.)
| | - Sheng Yu
- Center for Statistical Science, Tsinghua University, Beijing, China (S.Y.)
| | - Vivian Gainer
- Brigham and Women's Hospital, Boston, MA; Research Information Systems and Computing, Partners Healthcare, Boston, MA (V.M.C., V.G., S.M.)
| | | | - Guergana Savova
- Boston Children's Hospital Informatics Program, MA (S.F., G.S.)
| | - Shawn Murphy
- Brigham and Women's Hospital, Boston, MA; Research Information Systems and Computing, Partners Healthcare, Boston, MA (V.M.C., V.G., S.M.).,Department of Neurology, Massachusetts General Hospital, Boston (S.M.)
| | - Tianxi Cai
- Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA (T.C.)
| | - Scott T Weiss
- Channing Division of Network Medicine (S.T.W., R.D.)
| | - Rose Du
- From the Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.C., R.D.).,Channing Division of Network Medicine (S.T.W., R.D.)
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Abstract
Unruptured intracranial aneurysms (UIA) occur in approximately 2-3 % of the population. Most of these lesions are incidentally found, asymptomatic and typically carry a benign course. Although the risk of aneurysmal subarachnoid hemorrhage is low, this complication can result in significant morbidity and mortality, making assessment of this risk the cornerstone of UIA management. This article reviews important factors to consider when managing unruptured intracranial aneurysms including patient demographics, comorbidities, family history, symptom status, and aneurysm characteristics. It also addresses screening, monitoring, medical management and current surgical and endovascular therapies.
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20
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Patients with intracranial bleeding and atrial fibrillation treated with left atrial appendage occlusion: Results from the Amplatzer Cardiac Plug registry. Int J Cardiol 2017; 236:232-236. [DOI: 10.1016/j.ijcard.2017.02.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/24/2017] [Accepted: 02/10/2017] [Indexed: 11/21/2022]
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Fam MD, Pang A, Zeineddine HA, Mayo S, Stadnik A, Jesselson M, Zhang L, Dlugash R, Ziai W, Hanley D, Awad IA. Demographic Risk Factors for Vascular Lesions as Etiology of Intraventricular Hemorrhage in Prospectively Screened Cases. Cerebrovasc Dis 2017; 43:223-230. [PMID: 28245439 DOI: 10.1159/000458452] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/28/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Spontaneous intraventricular hemorrhage (IVH) is associated with high rates of morbidity and mortality despite critical care and other advances. An important step in clinical management is to confirm/rule out an underlying vascular lesion, which influences further treatment, potential for further bleeding, and prognosis. Our aim is to compare demographic and clinical characteristics between IVH patients with and without an underlying vascular lesion, and among cohorts with different vascular lesions. METHODS We analyzed prospectively collected data of IVH patients screened for eligibility as part of the Clot Lysis: Evaluation Accelerated Resolution of IVH Phase III (CLEAR III) clinical trial. The trial adopted a structured screening process to systematically exclude patients with an underlying vascular lesion as the etiology of IVH. We collected age, sex, ethnicity, and primary diagnosis on these cases and vascular lesions were categorized prospectively as aneurysm, vascular malformation (arteriovenous malformation, dural arteriovenous fistula, and cavernoma), Moyamoya disease, or other vascular lesion. We excluded cases <18 or >80 years of age. Baseline characteristics were compared between the CLEAR group (IVH screened without vascular lesion) and the group of IVH patients screened and excluded from CLEAR because of an identified vascular lesion. We further analyzed the differential demographic and clinical characteristics among subcohorts with different vascular lesions. RESULTS A total of 10,538 consecutive IVH cases were prospectively screened for the trial between 2011 and 2015. Out of these, 496 cases (4.7%) screened negative for underlying vascular lesion, met the inclusion criteria, and were enrolled in the trial (no vascular etiology group); and 1,205 cases (11.4%) were concurrently screened and excluded from the trial because of a demonstrated underlying vascular lesion (vascular etiology group). Cases with vascular lesion were less likely to be >45 years of age (OR 0.28, 95% CI 0.20-0.40), African-American (OR 0.23, 95% CI 0.18-0.31), or male gender (OR 0.48, 95% CI 0.38-0.60), and more likely to present with primary IVH (OR 1.85, 95% CI 1.37-2.51) compared to those with no vascular etiology (p < 0.001). Other demographic factors were associated with specific vascular lesion etiologies. A combination of demographic features increases the association with the absence of vascular lesion, but not with absolute reliability (OR 0.1, 95% CI 0.06-0.17, p < 0.001). CONCLUSION An underlying vascular lesion as etiology of IVH cannot be excluded solely by demographic parameters in any patient. Some form of vascular imaging is necessary in screening patients before contemplating interventions like intraventricular fibrinolysis, where safety may be impacted by the presence of vascular lesion.
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Affiliation(s)
- Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, IL, USA
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Dasenbrock HH, Yan SC, Gross BA, Guttieres D, Gormley WB, Frerichs KU, Ali Aziz-Sultan M, Du R. The impact of aspirin and anticoagulant usage on outcomes after aneurysmal subarachnoid hemorrhage: a Nationwide Inpatient Sample analysis. J Neurosurg 2017; 126:537-547. [DOI: 10.3171/2015.12.jns151107] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE
Although aspirin usage may be associated with a decreased risk of rupture of cerebral aneurysms, any potential therapeutic benefit from aspirin must be weighed against the theoretical risk of greater hemorrhage volume if subarachnoid hemorrhage (SAH) occurs. However, few studies have evaluated the association between prehemorrhage aspirin use and outcomes. This is the first nationwide analysis to evaluate the impact of long-term aspirin and anticoagulant use on outcomes after SAH.
METHODS
Data from the Nationwide Inpatient Sample (NIS; 2006–2011) were extracted. Patients with a primary diagnosis of SAH who underwent microsurgical or endovascular aneurysm repair were included; those with a diagnosis of an arteriovenous malformation were excluded. Multivariable logistic regression was performed to calculate the adjusted odds of in-hospital mortality, a nonroutine discharge (any discharge other than to home), or a poor outcome (death, discharge to institutional care, tracheostomy, or gastrostomy) for patients with long-term aspirin or anticoagulant use. Multivariable linear regression was used to evaluate length of hospital stay. Covariates included patient age, sex, comorbidities, primary payer, NIS-SAH severity scale, intracerebral hemorrhage, cerebral edema, herniation, modality of aneurysm repair, hospital bed size, and whether the hospital was a teaching hospital. Subgroup analyses exclusively evaluated patients treated surgically or endovascularly.
RESULTS
The study examined 11,549 hospital admissions. Both aspirin (2.1%, n = 245) and anticoagulant users (0.9%, n = 108) were significantly older and had a greater burden of comorbid disease (p < 0.001); severity of SAH was slightly lower in those with long-term aspirin use (p = 0.03). Neither in-hospital mortality (13.5% vs 12.6%) nor total complication rates (79.6% vs 80.0%) differed significantly by long-term aspirin use. Additionally, aspirin use was associated with decreased odds of a cardiac complication (OR 0.57, 95% CI 0.36%–0.91%, p = 0.02) or of venous thromboembolic events (OR 0.53, 95% CI 0.30%–0.94%, p = 0.03). Length of stay was significantly shorter (15 days vs 17 days [12.73%], 95% CI 5.22%–20.24%, p = 0.001), and the odds of a nonroutine discharge were lower (OR 0.63, 95% CI 0.48%–0.83%, p = 0.001) for aspirin users. In subgroup analyses, the benefits of aspirin were primarily noted in patients who underwent coil embolization; likewise, among patients treated endovascularly, the adjusted odds of a poor outcome were lower among long-term aspirin users (31.8% vs 37.4%, OR 0.63, 95% CI 0.42%–0.94%, p = 0.03). Although the crude rates of in-hospital mortality (19.4% vs 12.6%) and poor outcome (53.6% vs 37.6%) were higher for long-term anticoagulant users, in multivariable logistic regression models these variations were not significantly different (mortality: OR 1.36, 95% CI 0.89%–2.07%, p = 0.16; poor outcome: OR 1.09, 95% CI 0.69%–1.73%, p = 0.72).
CONCLUSIONS
In this nationwide study, neither long-term aspirin nor anticoagulant use were associated with differential mortality or complication rates after SAH. Aspirin use was associated with a shorter hospital stay and lower rates of nonroutine discharge, with these benefits primarily observed in patients treated endovascularly.
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Affiliation(s)
- Hormuzdiyar H. Dasenbrock
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
- 4H.T. Chan Harvard School of Public Health, Boston, Massachusetts
| | - Sandra C. Yan
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 5Warren Alpert School of Medicine, Brown University, Providence, Rhode Island; and
| | - Bradley A. Gross
- 6Barrow Neurological Institute, Division of Neurological Surgery, Phoenix, Arizona
| | | | - William B. Gormley
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
| | - Kai U. Frerichs
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
| | - M. Ali Aziz-Sultan
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
| | - Rose Du
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
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Unruptured Cerebral Aneurysms: Evaluation and Management. ScientificWorldJournal 2015; 2015:954954. [PMID: 26146657 PMCID: PMC4471401 DOI: 10.1155/2015/954954] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/30/2014] [Accepted: 12/15/2014] [Indexed: 11/21/2022] Open
Abstract
The evolution of imaging techniques and their increased use in clinical practice have led to a higher detection rate of unruptured intracranial aneurysms. The diagnosis of an unruptured intracranial aneurysm is a source of significant stress to the patient because of the concerns for aneurysmal rupture, which is associated with substantial rates of morbidity and mortality. Therefore, it is important that decisions regarding optimum management are made based on the comparison of the risk of aneurysmal rupture with the risk associated with intervention. This review provides a comprehensive overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management options for unruptured intracranial aneurysms based on the current evidence in the literature. Furthermore, the authors discuss the genetic abnormalities associated with intracranial aneurysm and current guidelines for screening in patients with a family history of intracranial aneurysms. Since there is significant controversy in the optimum management of small unruptured intracranial aneurysms, we provided a systematic approach to their management based on patient and aneurysm characteristics as well as the risks and benefits of intervention.
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Tsivgoulis G, Kontokostas S, Papageorgiou SG, Arvaniti C, Papathanasiou MA, Argentos S, Chondrogianni M, Stathis G, Voumvourakis K, Stefanis L. Resolution of unilateral obstructive hydrocephalus complicating expanding thrombosed basilar apex aneurysm after anticoagulation treatment. J Neurol Sci 2014; 341:179-81. [DOI: 10.1016/j.jns.2014.03.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 02/14/2014] [Accepted: 03/14/2014] [Indexed: 10/25/2022]
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Abstract
Unruptured intracranial aneurysms (UIA) are a common finding, occurring in about 2% of the population, making them very likely to be seen by most practitioners, and present a challenge in the recommendations for optimal management and screening. The consequences of aneurysm rupture are dire, with high likelihood of significant morbidity and mortality. Most aneurysms do not rupture and patients harboring these lesions often remain asymptomatic. There are effective surgical and endovascular interventions to prevent rupture, but these procedures carry a risk of adverse complications. This article addresses the challenges of screening and management of UIAs.
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