Cerebral vasospasm and delayed cerebral infarctions in 225 patients with non-aneurysmal subarachnoid hemorrhage: the underestimated risk of Fisher 3 blood distribution

Risk Factors for Cerebral Vasospasm After Subarachnoid Hemorrhage: A Systematic Review of Observational Studies

Cerebral vasospasm (CV) following subarachnoid hemorrhage (SAH) remains one of the leading causes of high mortality and poor outcomes. Understanding the risk factors associated with CV is pivotal to improving patients' outcomes. We conducted an extensive search for analytical observational studies that analyzed the correlation between various variables and the likelihood of CV development among adult patients with SAH (age ≥ 18 years). Five scholar databases were used, namely, PubMed, EBSCO, Web of Science, Science Direct, and Google Scholar. Relevant studies published between January 1st, 2016, and August 9th, 2023, were included. The Newcastle-Ottawa Scale was adopted to assess the risk of bias among included observational studies. A total of 33 studies met the inclusion criteria. Of the 24,958 patients with SAH who were identified, 6,761 patients had a subsequent CV (27.1%). Several statistically significant risk factors were reported across the literature. Younger age, female sex, smoking, alcohol intake, modified Fisher grade 3-4, higher Hunt and Hess grading, and the presence of multiple comorbidities (diabetes, hypertension, congestive heart failure, and history of stroke) were among the well-established risk factors for CV. Additionally, leukocytosis was consistently reported to be a significant predictor in multiple studies, providing compelling evidence for its association with CV. Even though single studies reported an association between CV and certain variables, further research is necessary to investigate the implications of these findings. These include arterial tortuosity, hypokalemia, potassium to glucose gradient, hypoalbuminemia, anemia, von Willebrand factor and vascular endothelial growth factor, use of desflurane, and hemodynamic stability. Overall, this systemic review provides a comprehensive summary of the current data that evaluates the potential risk factors for the development of CV after SAH. However, because of data heterogeneity, certain factors require further validation in their correlation with CV development. Larger-scale observational and clinical trials are mandatory to extensively investigate the significant predictors of CV to lay the scientific foundation for improving outcomes in susceptible patients with SAH.

Combined Transcranial Doppler and Melatonin Levels to Predict Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

OBJECTIVE

To investigate the early prediction value of transcranial Doppler ultrasound (TCD) combined with serum melatonin level for delayed cerebral ischemia (DCI) caused by subarachnoid hemorrhage (SAH).

METHODS

This paper is a prospective study. A total of 120 patients with SAH treated were included. The patients were divided into the DCI group (40 cases) and non-DCI group (80 cases) according to whether DCI occurred 14 days after SAH (DCI usually occurs 4 to 14 d after bleeding). Baseline data, serum melatonin level, and TCD test results within 24 hours after admission were compared between the 2 groups. Multivariate logistic analysis was used to analyze the factors affecting the occurrence of DCI after SAH. The value of serum melatonin level, middle cerebral artery mean blood flow velocity (MBFV) and their combination in predicting DCI in SAH patients was evaluated.

RESULTS

Univariate analysis showed that there were statistically significant differences in the proportion of Fisher grade, Hunt-Hess grade, serum melatonin level, middle cerebral artery systolic blood flow velocity (Vs), MBFV and pulse index (PI) between the 2 groups (P<0.05). Serum melatonin levels, middle cerebral artery Vs, MBFV, and PI in the DCI group were higher than those in non-DCI group. Logistic regression (LR) analysis showed that serum melatonin level (OR=1.796, 95% CI: 1.575-4.123) and middle cerebral artery MBFV (OR=3.279, 95% CI: 2.112-4.720] were the influencing factors for DCI in SAH patients (P<0.05).

CONCLUSION

Middle cerebral artery MBFV and serum melatonin levels were higher in patients with SAH complicated with DCI, and the combination of the 2 could provide a reference for early clinical prediction of DCI in patients with aneurysmal subarachnoid hemorrhage (aSAH).

The clinical course and outcomes of non-aneurysmal subarachnoid hemorrhages in a single-center retrospective study

BACKGROUND

Non-aneurysmal subarachnoid hemorrhages (SAHs) are thought to have a benign clinical course compared to aneurysmal SAHs. The aim of this study is to report the clinical course and outcomes of non-aneurysmal SAHs in a large single-center study.

METHODS

The patients with non-aneurysmal SAHs were screened from Tampere University Hospital from 2005 to 2020. The clinical data were collected from the patient's medical records and from the imaging studies. The primary interest was the neurological outcome assessed by dichotomized GOS at 2 months. Multivariable logistic regression was used to study the factors associated with unfavorable outcome.

RESULTS

We found 216 non-aneurysmal SAHs in 214 patients (2 patients with > 1 bleed). Ninety-seven percent of patients with a typical perimesencephalic bleeding pattern SAH (PSAH) (75/77) had a favorable outcome, while 86% of patients with non-perimesencephalic SAH (NPSAH) had a favorable outcome (84/98). In a multivariable logistic regression analysis, loss of consciousness (LOC) (aOR 214.67, 95% CI 17.62-2615.89) and Fisher grade 4 bleeding pattern (aOR 23.32, 95% CI 1.40-387.98) were associated with increased risk for unfavorable outcome (GOS 1-3). Vasospasm was seen in 20% of non-aneurysmal SAH patients, hydrocephalus in 17%, and 13% needed ventriculostomy.

CONCLUSIONS

Non-aneurysmal SAH seems to have a good prognosis for majority of patients, especially for patients with a PSAH. Non-aneurysmal SAH patients are however affected by vasospasm and hydrocephalus and have similar risk factors for poor outcome as patients with aneurysmal SAH. This suggests that it is the severity of the bleed rather than the etiology that associates with poor outcome.

Cost-effectiveness of repeat delayed imaging for spontaneous subarachnoid hemorrhage

BACKGROUND

In patients with intracranial aneurysm presenting with spontaneous subarachnoid hemorrhage (SAH), 15% of them could be missed by the initial diagnostic imaging. Repeat delayed imaging can help to identify previously undetected aneurysms, however, the cost-effectiveness of this strategy remains uncertain.

OBJECTIVE

The aim of this study is to assess the cost-effectiveness of repeat delayed imaging in patients with SAH who had a negative result during their initial imaging.

METHODS

A Markov model was developed to estimate the lifetime costs and quality-adjusted life-year (QALY) for patients who received or not received repeat delayed imaging. The analyses were conducted from a healthcare perspective, with costs reported in UK pounds and expressed in 2020 values. Extensive sensitivity analyses were performed to assess the robustness of the results.

RESULTS

The base case incremental cost-effectiveness ratio (ICER) of repeat delayed imaging is £9,314 per QALY compared to no-repeat delayed imaging. This ICER is below the National Institute for Health and Care Excellence (NICE) £20,000 per QALY willingness-to-pay threshold. At the NICE willingness-to-pay threshold of £20,000 per QALY, the probability that repeat delayed imaging is most cost-effective is 0.81. The results are sensitive to age, the utility of survived patients with a favorable outcome, the sensitivity of repeat delayed imaging, and the prevalence of aneurysm.

CONCLUSIONS

This study showed that, in the UK, it is cost-effective to provide repeat delayed imaging using computed tomographic angiography (CTA) for patients with SAH who had a negative result in their initial imaging.

Non-Aneurysmal Perimesencephalic Subarachnoid Hemorrhage: A Literature Review

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.

Treatment and outcomes of non-aneurysmal perimesencephalic subarachnoid haemorrhage: A 5 year retrospective study in a tertiary care centre

PURPOSE

Perimesencephalic Subarachnoid Haemorrhage (PMSAH) is an uncommon type of SAH. Severity of PMSAH can be graded by the presence of blood in the Sylvian fissure. No study compares the outcomes from PMSAH with blood present or absent in the Sylvian fissure. Furthermore, the use of Nimodipine lacks evidence base in PMSAH. We investigated whether continuing Nimodipine to 21 days in PMSAH with or without blood in the Sylvian fissure made any significant difference to patient outcome.

METHODS

Retrospective study of 93 cases admitted to tertiary centre from 2016 to 2020. We compared prevalence of cases with blood in Sylvian fissure, and analysed outcomes including complications and changes to patient modified rankin scale (MRS). We also audited use of Nimodipine in these cases and analysed whether Nimodipine made any significant difference in preventing complications.

RESULTS

91 % of PMSAH were grade 1, 24 cases (26 %) had blood in the Sylvian fissure. Sylvian fissure positive (Sylvian-positive) cases were statistically significantly more likely to have higher rates of complication compared to Sylvian fissure negative (Sylvian-negative) cases. Our centre stopped Nimodipine 56 % of the time in Sylvian-negative cases and 45 % of the time in Sylvian-positive cases. There was no statistically significant difference in outcomes when Nimodipine was continued to 21 days or ceased after negative angiogram; this result extended to both Sylvian-positive and Sylvian-negative subgroups when directly comparing Sylvian-positive cases with each other and Sylvian-negative cases likewise.

DISCUSSION

Sylvian-positive cases have a significantly higher rate of complication, as well as an increase in MRS. This may be because of the inflammatory properties of haemoglobin in the subarachnoid space post-bleed. Furthermore, acknowledging the limitations of our retrospective data, we did not find a statistically significant difference in continuing Nimodipine to 21 days with relation to PMSAH outcomes in all subgroups.

Current status of perimesencephalic non-aneurysmal subarachnoid hemorrhage

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a distinctive disease, representing SAH centered in perimesencephalic cisterns, with negative angiography findings. In recent years, the number of patients with PNSAH has increased significantly; however, the knowledge of PNSAH is insufficient. Therefore, we performed a review of the literature from a PubMed search and recounted our understanding of PNSAH. In this review, we summarized that current high-resolution computed tomography angiography is an acceptable replacement for digital subtraction angiography to rule out aneurysms in PNSAH with strict criteria. The current hypothesis about the etiology of PNSAH is that there is deep vein rupture from aberrant venous anatomy and increased intracranial venous pressure. PNSAH is associated with mild symptoms and lower rates of hydrocephalus and symptomatic vasospasm. For PNSAH, conservative treatment has been the mainstream treatment. PNSAH has a benign clinical course and an excellent prognosis; in long-term follow-up, re-bleeding and death were uncommon.

Clinical Outcome and Prognostic Factors of Patients with Perimesencephalic and Nonperimesencephalic Subarachnoid Hemorrhage

OBJECTIVE

To demonstrate the clinical outcome of patients with nonperimesencephalic subarachnoid hemorrhage (npSAH) compared with patients with aneurysmal SAH (aSAH) and perimesencephalic SAH (pSAH) and to evaluate predictive value of various clinical and radiological findings in patients with npSAH.

METHODS

We retrospectively identified patients with SAH who presented at our institution between 2009 and 2018. We analyzed demographic and clinical data and outcomes. Multivariable analysis was performed for outcome parameters.

RESULTS

Of 608 patients with confirmed SAH, 78% had aSAH, and 22% had nonaneurysmal SAH. Nonaneurysmal SAH was perimesencephalic in 30% of cases and nonperimesencephalic in 70%. Initial clinical status (Hunt and Hess score) was significantly worse in patients with aSAH compared with patients with nonaneurysmal SAH. Complications such as delayed cerebral ischemia occurred significantly more often in patients with aSAH. Patients with pSAH had a more favorable clinical course than patients with aSAH or npSAH. There was no significant difference in 30-day mortality between aSAH (29%) and npSAH (28%) patients (P = 0.835). Hunt and Hess score emerged as a strong predictor of unfavorable outcome in both aSAH and npSAH in multivariable regression.

CONCLUSIONS

Patients with npSAH had a similar clinical outcome as patients with aSAH, although there were significantly fewer clinical complications in patients with npSAH. Patients with pSAH demonstrated an overall good clinical course. Our multivariable analysis showed that initial Hunt and Hess score was an important predictor for clinical outcome in aSAH as well as npSAH.

Effect of stress-induced hyperglycemia after non-traumatic non-aneurysmal subarachnoid hemorrhage on clinical complications and functional outcomes

Background

Despite having an overall benign course, non‐traumatic non‐aneurysmal subarachnoid hemorrhage (naSAH) is still accompanied by a risk of clinical complications and poor outcomes. Risk factors and mechanisms of complications and poor outcomes after naSAH remain unknown. Our aim was to explore the effect of stress‐induced hyperglycemia (SIH) on complication rates and functional outcomes in naSAH patients.

Methods

We retrospectively reviewed patients with naSAH admitted to our institution between 2013 and 2018. SIH was identified according to previous criterion. Symptomatic vasospasm, delayed cerebral infarction, and hydrocephalus were identified as main complications. Outcomes were reviewed using a modified Rankin Scale (mRS) at discharge, 3 months, and 12 months. A statistical analysis was conducted to reveal the associations of SIH with complications and outcomes.

Results

A total of 244 naSAH patients were included in the cohort with 74 (30.3%) SIH. After adjusting for age, gender, hypertension, Hunt and Hess (HH) grade, modified Fisher Scale (mFS), intraventricular hemorrhage (IVH), and subarachnoid blood distribution, SIH was significantly associated with symptomatic vasospasm (p < 0.001, 12.176 [4.904–30.231]), delayed cerebral infarction (p < 0.001, 12.434 [3.850–40.161]), hydrocephalus (p = 0.008, 5.771 [1.570–21.222]), and poor outcome at 12 months (p = 0.006, 5.506 [1.632–18.581]), whereas the correlation between SIH and poor outcome at discharge (p = 0.064, 2.409 [0.951–6.100]) or 3 months (p = 0.110, 2.029 [0.852–4.833]) was not significant. Incorporation of SIH increased the area under curve (AUC) of ROC in the combined model for predicting symptomatic vasospasm (p = 0.002), delayed cerebral infarction (p = 0.024), hydrocephalus (p = 0.037), and 12‐month poor outcome (p = 0.087).

Conclusions

SIH is a significant and independent risk factor for symptomatic vasospasm, delayed cerebral infarction, hydrocephalus, and long‐term poor outcome in naSAH patients. Identifying SIH early after naSAH is important for decision‐making and treatment planning.

Arterial Wall Imaging in Angiographically Occult Spontaneous Subarachnoid Hemorrhage : New Insight into the Usual Suspect

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.

Short- and Long-Term Effects of Rehabilitation after Perimesencephalic Subarachnoid Hemorrhage

In about 25% of patients with spontaneous subarachnoid hemorrhage (SAH), a bleeding source cannot be identified during radiological diagnostics. Generally, the outcome of perimesencephalic or prepontine (PM) SAH is known to be significantly better than after non-PM SAH. Data about long-term follow-up concerning physical and mental health are scarce, so this study is reports on long-term results. We measured the influence of PM SAH on a quality-of-life modified Rankin (mRs) scale after six months. For long-term follow-up, a SF-36 questionnaire was used. Questionnaires were sent out between 18 and 168 months after ictus. In 37 patients, a long-term follow-up was available (up to 14 years after SAH). Data detected with the SF-36 questionnaire are compared to reference applicability to the standard population. In total, 37 patients were included for further analysis and divided in 2 subgroups; 13 patients (35%) received subsequent rehabilitation after clinical stay and 24 (65%) did not. In the short-term outcome, a significant improvement from discharge until follow-up was identified in patients with subsequent rehabilitation, but not in the matched pair group without rehabilitation. When PM SAH was compared to the standard population, a reduction in quality of life was identified in physical items (role limitations because of physical health problems, physical functioning) as well as in psychological items (role limitations because of emotional problems). Subsequent rehabilitation on PM SAH patients probably leads to an increase in independence and better mRs. While better mRs was shown at discharge in patients without subsequent rehabilitation, the mRs of rehabilitants was nearly identical after rehabilitation. Patients with good mRs also reached high levels of health-related quality of life (HRQoL) without rehabilitation. Thus, subsequent rehabilitation needs to be encouraged on an individual basis. Indication criteria for subsequent rehabilitation should be defined in further studies to improve patient treatment and efficiency in health care.

Baseline characteristics and outcome for aneurysmal versus non-aneurysmal subarachnoid hemorrhage: a prospective cohort study

This study aims to investigate the characteristics of patients with mild aneurysmal and non-aneurysmal perimesencephalic and non-perimesencephalic subarachnoid hemorrhage (aSAH, pmSAH, npmSAH) with emphasis on admission biomarkers, clinical course, and outcome. A prospective cohort of 115 patients with aSAH (Hunt and Hess 1–3) and of 35 patients without aneurysms (16 pmSAH and 19 npmSAH) admitted between January 2014 and January 2020 was included. Demographic data, blood samples on admission, complications (hydrocephalus, shunt dependency, delayed cerebral ischemia DCI, DCI-related infarction, and mortality), and outcome after 6 months were analyzed. Demographic data was comparable between all groups except for age (aSAH 55 [48–65] vs. npmSAH 60 [56–68] vs. pmSAH 52 [42–60], p = 0.032) and loss of consciousness (33% vs. 0% vs. 0%, p = 0.0004). Admission biomarkers showed poorer renal function and highest glucose levels for npmSAH patients. Complication rate in npmSAH was high and comparable to that of aSAH patients (hydrocephalus, shunt dependency, DCI, DCI-related infarction, mortality), but nearly absent in patients with pmSAH. Favorable outcome after 6 months was seen in 92.9% of pmSAH, 83.3% of npmSAH, and 62.7% of aSAH (p = 0.0264). In this prospective cohort of SAH patients, npmSAH was associated with a complicated clinical course, comparable to that of patients with aSAH. In contrast, such complications were nearly absent in pmSAH patients, suggesting fundamental differences in the pathophysiology of patients with different types of non-aneurysmal hemorrhage. Our findings underline the importance for a precise terminology according the hemorrhage etiology as a basis for more vigilant management of npmSAH patients. NCT02142166, 05/20/2014, retrospectively registered.

Elevation of CSF Sortilin Following Subarachnoid Hemorrhage in Patients and Experimental Model Rats

Subarachnoid hemorrhage (SAH) can cause acute neuronal injury and chronic neurocognitive deficits; biomarkers reflecting its associated neuronal injury are of potential prognostic value. Sortilin, a member of the vacuolar protein sorting 10p (Vps10p) family, is enriched in neurons and is likely involved in neurodegenerative diseases. Here, we explored sortilin in the cerebrospinal fluid (CSF) as a potential biomarker for early neuronal injury after SAH. Sortilin levels in the CSF of SAH patients (n = 11) and controls (n = 6) were analyzed by immunoblot. SAH rats surviving 3-72 h (h) were evaluated neurologically, with their brain and CSF samples examined histologically and biochemically. Sortilin protein ~100 kDa was detected in the CSF from SAH patients only, with its levels correlated to Hunt-Hess scale. Rats in the SAH groups showed poorer Garcia score and beam balancing capability than sham controls. Sortilin ~100 kDa was detectable in the CSF of the SAH, but not sham, animals. Levels of sortilin ~100 kDa and fragments ~40 kDa in cortical lysates were elevated in the SAH relative to control rats. Levels of cortical glial fibrillary acidic protein (GFAP) were also elevated in the SAH rats. In immunohistochemistry, the pattern of sortilin labeling in the brain was largely comparable between the SAH and control rats, whereas an increased astrocytic GFAP immunolabeling was evident in the former. Together, these results suggest that SAH can cause an early and remarkable rise of sortilin products in CSF, likely reflecting neuronal change. Sortilin could be further explored as a potential biomarker in some brain disorders.

Statins Improve Clinical Outcome After Non-aneurysmal Subarachnoid Hemorrhage: A Translational Insight From a Systematic Review of Experimental Studies

The efficacy of statin-treatment in aneurysmal subarachnoid hemorrhage (SAH) remains controversial. We aimed to investigate the effects of statin-treatment in non-aneurysmal (na)SAH in accordance with animal research data illustrating the pathophysiology of naSAH. We systematically searched PubMed using PRISMA-guidelines and selected experimental studies assessing the statin-effect on SAH. Detecting the accordance of the applied experimental models with the pathophysiology of naSAH, we analyzed our institutional database of naSAH patients between 1999 and 2018, regarding the effect of statin treatment in these patients and creating a translational concept. Patient characteristics such as statin-treatment (simvastatin 40 mg/d), the occurrence of cerebral vasospasm (CVS), delayed infarction (DI), delayed cerebral ischemia (DCI), and clinical outcome were recorded. In our systematic review of experimental studies, we found 13 studies among 18 titles using blood-injection-animal-models to assess the statin-effect in accordance with the pathophysiology of naSAH. All selected studies differ on study-setting concerning drug-administration, evaluation methods, and neurological tests. Patients from the Back to Bedside project, including 293 naSAH-patients and 51 patients with simvastatin-treatment, were recruited for this analysis. Patients under treatment were affected by a significantly lower risk of CVS (p < 0.01; OR 3.7), DI (p < 0.05; OR 2.6), and DCI (p < 0.05; OR 3). Furthermore, there was a significant association between simvastatin-treatment and favorable-outcome (p < 0.05; OR 3). However, dividing patients with statin-treatment in pre-SAH (n = 31) and post-SAH (n = 20) treatment groups, we only detected a tenuously significant higher chance for a favorable outcome (p < 0.05; OR 0.05) in the small group of 20 patients with statin post-SAH treatment. Using a multivariate-analysis, we detected female gender (55%; p < 0.001; OR 4.9), Hunt&Hess ≤III at admission (p < 0.002; OR 4), no anticoagulant-therapy (p < 0.0001; OR 0.16), and statin-treatment (p < 0.0001; OR 24.2) as the main factors improving the clinical outcome. In conclusion, we detected a significantly lower risk for CVS, DCI, and DI in naSAH patients under statin treatment. Additionally, a significant association between statin treatment and favorable outcome 6 months after naSAH onset could be confirmed. Nevertheless, unified animal experiments should be considered to create the basis for developing new therapeutic schemes.

Interleukin 6 and Aneurysmal Subarachnoid Hemorrhage. A Narrative Review

Interleukin 6 (IL-6) is a prominent proinflammatory cytokine. Neuroinflammation in general, and IL-6 signaling in particular, appear to play a major role in the pathobiology and pathophysiology of aneurysm formation and aneurysmal subarachnoid hemorrhage (SAH). Most importantly, elevated IL-6 CSF (rather than serum) levels appear to correlate with delayed cerebral ischemia (DCI, “vasospasm”) and secondary (“vasospastic”) infarctions. IL-6 CSF levels may also reflect other forms of injury to the brain following SAH, i.e., early brain damage and septic complications of SAH and aneurysm treatment. This would explain why many researchers have found an association between IL-6 levels and patient outcomes. These findings clearly suggest CSF IL-6 as a candidate biomarker in SAH patients. However, at this point, discrepant findings in variable study settings, as well as timing and other issues, e.g., defining proper clinical endpoints (i.e., secondary clinical deterioration vs. angiographic vasospasm vs. secondary vasospastic infarct) do not allow for its routine use. It is also tempting to speculate about potential therapeutic measures targeting elevated IL-6 CSF levels and neuroinflammation in SAH patients. Corticosteroids and anti-platelet drugs are indeed used in many SAH cases (not necessarily with the intention to interfere with detrimental inflammatory signaling), however, no convincing benefit has been demonstrated yet. The lack of a robust clinical perspective against the background of a relatively large body of data linking IL-6 and neuroinflammation with the pathophysiology of SAH is somewhat disappointing. One underlying reason might be that most relevant studies only report correlative data. The specific molecular pathways behind elevated IL-6 levels in SAH patients and their various interactions still remain to be delineated. We are optimistic that future research in this field will result in a better understanding of the role of neuroinflammation in the pathophysiology of SAH, which in turn, will translate into the identification of suitable biomarkers and even potential therapeutic targets.

Multidrug-resistant organisms (MDROs) in patients with subarachnoid hemorrhage (SAH)

Patient care in a neurointensive care unit (neuro-ICU) is challenging. Multidrug-resistant organisms (MDROs) are increasingly common in the routine clinical practice. We evaluated the impact of infection with MDROs on outcomes in patients with subarachnoid hemorrhage (SAH). A single-center retrospective analysis of SAH cases involving patients treated in the neuro-ICU was performed. The outcome was assessed 6 months after SAH using the modified Rankin Scale [mRS, favorable (0–2) and unfavorable (3–6)]. Data were compared by matched-pair analysis. Patient characteristics were well matched in the MDRO (n = 61) and control (n = 61) groups. In this center, one nurse was assigned to a two-bed room. If a MDRO was detected, the patient was isolated, and the nurse was assigned to the patient infected with the MDRO. In the MDRO group, 29 patients (48%) had a favorable outcome, while 25 patients (41%) in the control group had a favorable outcome; the difference was not significant (p > 0.05). Independent prognostic factors for unfavorable outcomes were worse status at admission (OR = 3.1), concomitant intracerebral hematoma (ICH) (OR = 3.7), and delayed cerebral ischemia (DCI) (OR = 6.8). Infection with MRDOs did not have a negative impact on the outcome in SAH patients. Slightly better outcomes were observed in SAH patients infected with MDROs, suggesting the benefit of individual care.

Novel Subgroups in Subarachnoid Hemorrhage and Their Association With Outcomes-A Systematic Review and Meta-Regression

Background and Purpose: Subarachnoid hemorrhage (SAH) has long been classified into two main forms, aneurysmal SAH (aSAH) and non-aneurysmal SAH (naSAH), but the related risk factors for aSAH and naSAH are heterogeneous. Our objective was to determine the risk factors for SAH of known or unknown origin with respect to diagnostic evaluation in a large patient cohort. We sought to determine whether our classification system can further predict middle long-term stroke and death. Methods: We performed a systematic review and meta-analysis to identify risk factors for each SAH subtype. The discovery phase analyzed 11 risk factors from case studies in the literature. Kruskal-Wallis, Cox regression, logistic regression, and Kaplan-Meier analyses were used to compare the two groups. Results: A total of 14,904 (34.53%) male and 22,801 (52.84%) female patients were eligible for this study. At a median follow-up of 45.6 months, the 5-years overall survival was 97.768% (95% CI: 0.259-0.292) for aSAH patients and 87.904% (95% CI: 1.459-1.643) for naSAH patients. The 10-years survival rate was 93.870% (95% CI: 2.075-3.086) and 78.115% (95% CI: 2.810-3.156), respectively. Multi-risk factor subgroups showed significant intergroup differences. We identified eight risk factors (drugs, trauma, neoplastic, vessels lesion, inflammatory lesion, blood disease, aneurysm, peri-mesencephalic hemorrhage) using logistic regression, which were optimally differentiated among the aSAH [aSAH-S (AUC: 1), a-d-SAH (AUC: 0.9998), aSAH-T (AUC: 0.9199), aSAH-N (AUC: 0.9433), aSAH-V (AUC: 1), aSAH-I (AUC: 0.9954), a-bd-SAH (AUC: 0.9955)] and naSAH [na-pmSAH (AUC: 0.9979), na-ni-ivl-SAH (AUC: 1), na-t-SAH (AUC: 0.9997), na-ne-SAH (AUC: 0.9475), na-d-SAH (AUC: 0.7676)] subgroups. These models were applied in a parallel cohort, showing eight risk factors plus survival rates to predict the prognosis of SAH. Conclusions: The classification of risk factors related to aSAH and naSAH is helpful in the diagnosis and prediction of the prognosis of aSAH and naSAH patients. Further validation is needed in future clinical applications.

Interleukin 6 in cerebrospinal fluid is a biomarker for delayed cerebral ischemia (DCI) related infarctions after aneurysmal subarachnoid hemorrhage

Interleukin 6 (IL-6) is a prominent proinflammatory cytokine and has been discussed as a potential biomarker for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage. In the present study we have analyzed the time course of serum and cerebrospinal fluid (CSF) IL-6 levels in 82 patients with severe aneurysmal subarachnoid hemorrhage (SAH) requiring external ventricular drains in correlation to angiographic vasospasm, delayed cerebral ischemia, secondary infarctions and other clinical parameters. We observed much higher daily mean IL-6 levels (but also large interindividual variations) in the CSF than the serum of the patients with a peak between days 4 and 14 including a maximum on day 5 after SAH. Individual CSF peak levels correlated significantly with DCI (mean day 4–14 peak, DCI: 26,291 ± 24,159 pg/ml vs. no DCI: 16,184 ± 13,163 pg/ml; P = 0.023). Importantly, CSF IL-6 levels differed significantly between cases with DCI and infarctions and patients with DCI and no infarction (mean day 4–14 peak, DCI with infarction: 37,209 ± 26,951 pg/ml vs. DCI, no infarction: 15,123 ± 11,239 pg/ml; P = 0.003), while findings in the latter patient group were similar to cases with no vasospasm (mean day 4–14 peak, DCI, no infarction: 15,123 ± 11,239 vs. no DCI: 15,840 ± 12,979; P = 0.873). Together, these data support a potential role for elevated CSF IL-6 levels as a biomarker for DCI with infarction rather than for DCI in general. This fits well with a growing body of evidence linking neuroinflammation to ischemia and infarction, but (together with the large interindividual variations observed) limits the diagnostic usefulness of CSF IL-6 levels in SAH patients.

Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis

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.

The Nimodipine-Sparing Effect of Perioperative Dexmedetomidine Infusion During Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized, Controlled Trial

Background: Nimodipine can block the influx of calcium into the vascular smooth muscle cell and prevent secondary ischemia in patients with aneurysmal subarachnoid hemorrhage. However, the reduction of blood pressure after long-term intravenous administration of nimodipine has been associated with neurological deterioration. Yet, no effective solutions have been suggested to address this phenomenon. The use of neuroprotective drug combinations may reduce the risk of sudden blood pressure loss. This prospective, randomized, controlled trial was performed to evaluate the nimodipine-sparing effect of perioperative dexmedetomidine infusion during aneurysmal subarachnoid hemorrhage.

Methods: One hundred nine patients who underwent aneurysm embolization were divided into three groups: group C (n = 35, infused with 0.9% sodium chloride at the same rate as other two groups), group D1 (n = 38, dexmedetomidine infusion at 0.5 µg·kg^–1 for 10 min, then adjusted to 0.2 µg·kg^–1·h^–1), and group D2 (n = 36, dexmedetomidine infusion at 0.5 µg·kg^–1 for 10 min, then adjusted to 0.4 µg·kg^–1·h^–1). Patient-controlled analgesia was given for 48 h after surgery. The primary outcome measure was the total consumption of nimodipine during the first 48 h after surgery. The secondary outcome measures were recovery time at post-anesthesia care unit (PACU), postoperative pain intensity scores, dexmedetomidine and sufentanil consumption, hemodynamic, satisfaction of patients and neurosurgeon, neurologic examination (Glasgow Coma Scale, GCS), Bruggemann comfort scale, and adverse effects. Intraoperative hemodynamics were recorded at the following time-points: arrival at the operating room (T1); before intubation (T2); intubation (T3); 5 min (T4), 10 min (T5), and 15 min (T6) after intubation; suturing of femoral artery (T7); end of surgery (T8); extubation (T9); and 5 min (T10), 10 min (T11), and 15 min (T12) after arrival at the PACU. The level of sedation was recorded at 15 min, 30 min, 1 h, and 2 h after extubation. We also recorded the incidence of symptomatic cerebral vasospasm during 7 days after surgery, Glasgow Outcome Score (GOS) at 3 months, and incidence of cerebral infarction 30 days after surgery.

Results: The consumption of nimodipine during the first 48 h after surgery was significantly lower in group D2 (P < 0.05). Compared with group C, HR and MAP were significantly decreased from T2 to T12 in group D1 and D2 (P < 0.05). Patients in group D2 showed a significantly decreased MAP from T5 to T9 compared with group D1 (P < 0.05). The consumption of sevoflurane, remifentanil, dexmedetomidine, and nimodipine were all significantly reduced in groups D1 and D2 during surgery (P < 0.05). Compared with group C, MAP was significantly decreased in groups D1 and D2 during the first 48 h after surgery (P < 0.05). Compared with group C, consumption of sufentanil and dexmedetomidine at 1 h, pain intensity at 1 h, and 8 h after surgery were significantly decreased in groups D1 and D2 (P < 0.05). FAS was significantly higher in group D2 at 8 h, 16 h, and 24 h after surgery. LOS was significantly lower only in group D2 at 0.5 h after surgery (P < 0.05). Compared with group C, BCS was significantly higher group D2 at 4 h and 8 h after surgery (P < 0.05). There were no significant differences among the three groups in consumption of propofol, cisatracurium, fentanyl, and vasoactive drugs during operation, recovery time at PACU, satisfaction of patients and neurosurgeon, and number of applied urapidil and GCS during the first 48 h after surgery. The incidence of symptomatic cerebral vasospasm during 7 days after surgery, GOS of 3 months, and cerebral infarction after 30 days were also comparable among the three groups.

Conclusions: Dexmedetomidine (infusion at 0.5 µg·kg^–1 for 10 min, then adjusted to 0.4 µg·kg^–1·h^–1 during the surgery) significantly reduced the total consumption of nimodipine during the first 48 h after surgery and promoted early rehabilitation of patients although the incidences of symptomatic cerebral vasospasm, GOS, and cerebral infarction were not reduced.

Cerebral vasospasm after endoscopic fenestration of a temporal arachnoid cyst in a child-a case report and review of the literature

INTRODUCTION

Intracranial arachnoid cysts (ACs) represent rare extra-axial CSF-containing lesions. Surgical management mainly depends on the cyst location and its size. Nevertheless, pure endoscopic fenestration represents a relatively straightforward and safe technique, and-in most cases-the treatment of choice for symptomatic intracranial ACs. The postoperative complication rate of the procedure is low including subdural hematomas, hygromas, and intraparenchymal hemorrhages. Symptomatic cerebral vasospasm after endoscopic treatment of ACs is a very uncommon event.

CASE REPORT/RESULTS

To the authors' knowledge, this adverse event in children has not yet been reported in the literature yet. The authors present a case of a 9-year-old child developing an early symptomatic cerebral vasospasm with an insignificant secondary ischemia following endoscopic fenestration of a large temporal arachnoid cyst.

DISCUSSION

The clinical approach, possible pathogenesis, and the therapeutic strategy is discussed particularly with regard to the literature.

Ischemic Lesions in Acute and Subacute Perimesencephalic Subarachnoid Hemorrhage

OBJECTIVE

Perimesencephalic hemorrhage (PMH) is a subtype of nonaneurysmal subarachnoid hemorrhage (SAH). In patients with aneurysmal SAH, the occurrence of acute ischemic lesions is associated with severity and poor outcome. We investigated the frequency of ischemic lesions on DWI in patients with PMH and compared it with the frequency of ischemic lesions in patients with aneurysmal SAH.

SUBJECTS AND METHODS

From a prospective cohort of 80 patients with acute spontaneous SAH, we included 15 patients with PMH and 39 patients with aneurysmal SAH who were matched on the basis of their clinical condition (World Federation of Neurological Societies grade 1 or 2). MRI was performed less than 72 hours after SAH, 8-10 days after SAH, or at both points in time. The number and distribution of lesions previously seen on DWI that were also seen on a second MRI examination were assessed. Nonparametric tests were used to compare groups.

RESULTS

Early acute ischemic lesions (those identified < 72 hours after SAH) were found in 46.2% of patients with PMH and in 62.9% of patients with aneurysmal SAH. No significant differences in the number of acute ischemic lesions between groups were noted less than 72 hours after SAH (median, 0.5 lesion [interquartile range {IQR}, two lesions] in patients with PMH vs one lesion [IQR, three lesions] in patients with aneurysmal SAH [p = 0.48] or 8-10 days after SAH (median, 0.5 lesion [IQR, four lesions] in patients with PMH vs 1.5 lesions [IQR, three lesions] in patients with aneurysmal SAH [p = 0.26]). However, 58.3% of patients with aneurysmal SAH had new infarcts at 8-10 days, compared with 7.1% of patients with PMH. Patients with PMH had diffuse ischemic lesions, whereas patients with aneurysmal SAH in the anterior circulation had mainly supratentorial lesions.

CONCLUSION

Early ischemic lesions appeared on DWI both in patients with PMH and in patients with aneurysmal SAH. The number of lesions increased during the time window for vasospasm, mainly in patients with aneurysmal SAH. Further studies are required to better understand the pathophysiologic mechanisms behind early ischemia in patients with PMH and their impact on prognosis.

Elevated C-reactive protein and white blood cell count at admission predict functional outcome after non-aneurysmal subarachnoid hemorrhage

INTRODUCTION

Patients with non-aneurysmal subarachnoid hemorrhage (SAH) are considered to have an overall benign course of disease compared to patients suffering from aneurysmal SAH. Nevertheless, a small but significant number of such patients might only achieve unfavorable outcome. Therefore, the purpose of the present study was to determine if routine laboratory markers of acute phase response are associated with unfavorable outcome in patients with non-aneurysmal SAH.

METHODS

From 2006 to 2017, 154 patients suffering from non-aneurysmal SAH were admitted to our institution. Patients were stratified according to the distribution of cisternal blood into patients with perimesencephalic SAH (pSAH) versus non-perimesencephalic SAH (npSAH). C-reactive protein (CRP) and white blood cells (WBC) assessments were performed within 24 h of admission as part of routine laboratory workup. Outcome was assessed according to the modified Rankin Scale (mRS) after 6 months and stratified into favorable (mRS 0-2) vs. unfavorable (mRS 3-6).

RESULTS

The multivariate regression analysis revealed "CRP > 5 mg/l" (p = 0.004, OR 143.7), "WBC count > 12.1 G/l" (p = 0.006, OR 47.8), "presence of IVH" (p = 0.02, OR 13.5), "poor-grade SAH" (p = 0.01, OR 45.2) and "presence of CVS" (p = 0.003, OR 149.9) as independently associated with unfavorable outcome in patients with non-aneurysmal SAH.

CONCLUSION

Elevated C-reactive protein and WBC count at admission were associated with unfavorable outcome after non-aneurysmal SAH.

Delayed Cerebral Ischemia and Vasospasm After Spontaneous Angiogram-Negative Subarachnoid Hemorrhage: An Updated Meta-Analysis

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.

Influence of ABO blood type on the outcome after non-aneurysmal subarachnoid hemorrhage

BACKGROUND

In patients with non-aneurysmal subarachnoid hemorrhage (NA-SAH), the etiology is unknown and the bleeding source remains unidentified. However, the ABO blood type system has a profound role in patient's hemostasis and thrombosis. To date, the aspect of ABO blood type in incidence, clinical course, and outcome after NA-SAH has not been investigated.

METHODS

In this retrospective analysis, 81 patients with non-traumatic and non-aneurysmal subarachnoid hemorrhage treated between 2010 and 2014 at the author's institution were included. WFNS admission status, cerebral vasospasm, delayed infarction, ventriculoperitoneal shunt necessity, the Fisher grade, and the modified Rankin Scale were analyzed for their association with ABO blood type. Four hundred seventy patients with aneurysmal subarachnoid hemorrhage served as a control group.

RESULTS

The AB blood type is more frequent in NA-SAH compared to aneurysmal patients and the German population (OR 2.45, p ≤ 0.05). Furthermore, NA-SAH with AB blood type showed a similar sequelae compared to aneurysmal patients in terms of shunt necessity (OR 2.00, p ≥ 0.05), cerebral vasospasm (OR 1.66, p ≥ 0.05), and delayed infarctions (OR 1.07, p ≥ 0.05).

CONCLUSION

The clinical course of NA-SAH AB blood type patients shows similar severity as of aneurysmal subarachnoid hemorrhage. Therefore, patients with AB blood type should be under intensified observation.

The Clinical Value of d-Dimer Level in Patients with Nonaneurysmal Subarachnoid Hemorrhage

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.

Risk factors for shunt dependency in patients suffering from spontaneous, non-aneurysmal subarachnoid hemorrhage

Patients presenting with spontaneous, non-aneurysmal subarachnoid hemorrhage (SAH) achieve better outcomes compared to patients with aneurysmal SAH. Nevertheless, some patients develop shunt-dependent hydrocephalus during treatment course. We therefore analyzed our neurovascular database to identify factors determining shunt dependency after non-aneurysmal SAH. From 2006 to 2016, 131 patients suffering from spontaneous, non-aneurysmal SAH were admitted to our department. Patients were stratified according to the distribution of cisternal blood into patients with perimesencephalic SAH (pSAH) versus non-perimesencephalic SAH (npSAH). Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months and stratified into favorable (mRS 0-2) versus unfavorable (mRS 3-6). A multivariate analysis was performed to identify predictors of shunt dependency in patients suffering from non-aneurysmal SAH. Overall, 18 of 131 patients suffering from non-aneurysmal SAH developed shunt dependency (14%). In detail, patients with npSAH developed significantly more often shunt dependency during treatment course, when compared to patients with pSAH (p = 0.02). Furthermore, patients with acute hydrocephalus, presence of intraventricular hemorrhage, presence of clinical vasospasm, and anticoagulation medication prior SAH developed significantly more often shunt dependency, when compared to patients without (p < 0.0001). However, "acute hydrocephalus" was the only significant and independent predictor for shunt dependency in all patients with non-aneurysmal SAH in the multivariate analysis (p < 0.0001). The present study identified acute hydrocephalus with the necessity of CSF diversion as significant and independent risk factor for the development of shunt dependency during treatment course in patients suffering from non-aneurysmal SAH.

Cerebral Vasospasm-Dependent and Cerebral Vasospasm-Independent Cerebral Infarctions Predict Outcome After Nonaneurysmal Subarachnoid Hemorrhage: A Single-Center Series with 250 Patients

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).

Aneurysmal Subarachnoid Hemorrhage and Neuroinflammation: A Comprehensive Review

Aneurysmal subarachnoid hemorrhage (SAH) can lead to devastating outcomes including vasospasm, cognitive decline, and even death. Currently, treatment options are limited for this potentially life threatening injury. Recent evidence suggests that neuroinflammation plays a critical role in injury expansion and brain damage. Red blood cell breakdown products can lead to the release of inflammatory cytokines that trigger vasospasm and tissue injury. Preclinical models have been used successfully to improve understanding about neuroinflammation following aneurysmal rupture. The focus of this review is to provide an overview of how neuroinflammation relates to secondary outcomes such as vasospasm after aneurysmal rupture and to critically discuss pharmaceutical agents that warrant further investigation for the treatment of subarachnoid hemorrhage. We provide a concise overview of the neuroinflammatory pathways that are upregulated following aneurysmal rupture and how these pathways correlate to long-term outcomes. Treatment of aneurysm rupture is limited and few pharmaceutical drugs are available. Through improved understanding of biochemical mechanisms of injury, novel treatment solutions are being developed that target neuroinflammation. In the final sections of this review, we highlight a few of these novel treatment approaches and emphasize why targeting neuroinflammation following aneurysmal subarachnoid hemorrhage may improve patient care. We encourage ongoing research into the pathophysiology of aneurysmal subarachnoid hemorrhage, especially in regards to neuroinflammatory cascades and the translation to randomized clinical trials.