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Al-Salihi MM, Gillani SA, Saha R, Abd Elazim A, Al-Jebur MS, Al-Salihi Y, Ayyad A, Nattanmai P, Siddiq F, Gomez CR, Qureshi AI. Clinical Characteristics as Predictors of Early and Delayed Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage Patients: A Meta-Analysis of 4527 Cases. World Neurosurg 2024; 189:373-380.e3. [PMID: 38906475 DOI: 10.1016/j.wneu.2024.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/12/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Predictors of delayed cerebral infarction (DCI) and early cerebral infraction (ECI) among aneurysmal subarachnoid hemorrhage (aSAH) patients remain unclear. We aimed to systematically review and synthesize the literature on predictors of ECI and DCI among aSAH patients. METHODS We systematically searched PubMed, EMBASE, Cochrane Library, and Scopus databases comprehensively from inception through January 2024 for observational cohort studies examining predictors of DCI or ECI following aneurysmal SAH. Studies were screened, reviewed, and meta-analyzed, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines. The data were pooled as Odds ratios (OR) with 95% confidence intervals using Review Manager 5.4 software. Methodologic quality was assessed with the Newcastle-Ottawa Scale. RESULTS Our meta-analysis included 12 moderate to high-quality cohort studies comprising 4527 patients. Regarding DCI predictors, Higher severity scores (OR = 1.49, 95% confidence interval [1.12, 1.97], P = 0.005) and high Fisher scores (OR = 2.23, 95% confidence interval [1.28, 3.89], P = 0.005) on presentation were significantly associated with an increased risk of DCI. Also, the female sex and the presence of vasospasm were significantly associated with an increased risk of DCI (OR = 3.04, 95% confidence interval [1.35, 6.88], P = 0.007). In contrast, preexisting hypertension (P = 0.94), aneurysm treatment (P = 0.14), and location (P = 0.16) did not reliably predict DCI risk. Regarding ECI, the pooled analysis demonstrated no significant associations between sex (P = 0.51), pre-existing hypertension (P = 0.63), severity (P = 0.51), or anterior aneurysm location versus posterior (P = 0.86) and the occurrence of ECI. CONCLUSION Female sex, admission disease severity, presence of vasospasm and Fisher grading can predict DCI risk post-aSAH. Significant knowledge gaps exist for ECI predictors. Further large standardized cohorts are warranted to guide prognosis and interventions.
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Affiliation(s)
- Mohammed Maan Al-Salihi
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.
| | - Syed A Gillani
- Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri, USA; Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Ram Saha
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ahmed Abd Elazim
- Department of Neurology, University of South Dakota, Sioux Falls, South Dakota, USA
| | | | | | - Ali Ayyad
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
| | | | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri, USA; Department of Neurology, University of Missouri, Columbia, Missouri, USA
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Ma L, Hoz SS, Al-Bayati AR, Nogueira RG, Lang MJ, Gross BA. Sustained efficacy of angioplasty for cerebral vasospasm after aneurysmal subarachnoid hemorrhage: Risk features and device comparison. J Clin Neurosci 2024; 128:110784. [PMID: 39142039 DOI: 10.1016/j.jocn.2024.110784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/26/2024] [Accepted: 08/10/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Cerebral vasospasm is a leading source of delayed morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Angioplasty may improve vasospasm, while optimal target and device selection remains controversial. This study aimed to identify features and devices associated with sustained efficacy. METHODS We identified consecutive patients who underwent angioplasty for aSAH vasospasm. The primary outcome was a composite of adequate angioplasty (residual narrowing < 50 %) without complications. Secondary outcomes included rates of refractory/recurrent vasospasm and sustained improvement at follow-up. Associated features were identified through multivariable analysis. Outcomes were compared between balloon and Comaneci/stentriever in a propensity-score-matched cohort. RESULTS A total of 149 vasospastic segments underwent angioplasty: 61.7 % in the proximal anterior circulation (ICA, M1, A1), 20.1 % in distal segments (A2 and M2) and 18.1 % in the posterior circulation. Adequate angioplasty was achieved without complication in 83.2 % of vessels, with a sustainable effect in 84.3 % at follow-up. Refractory/recurrent vasospasm was observed in 17.4 %, yielding a 10.1 % retreatment rate. Notably, only 35.3 % of vessels undergoing inadequate angioplasty demonstrated improvement at follow-up. Angioplasty targeting distal MCA (adjusted OR, 0.10) or BA-V4 (aOR, 0.10), and inadequate angioplasty (aOR, 0.03) were unfavorable predictors for sustained improvement. Efficacy outcomes were similar between balloon and Comaneci/stentriever in a matched subgroup analysis. CONCLUSION Angioplasty, when achieving residual narrowing < 50 %, demonstrated sustained improvement for vasospasm. Novel devices may exhibit comparable efficacy to balloon angioplasty for selected segments.
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Affiliation(s)
- Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Samer S Hoz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Alhamza R Al-Bayati
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States.
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Wu R, Hu F, Liu C, Liang J. The value of modified hijdra score in patients with aneurysmal subarachnoid hemorrhage. Heliyon 2024; 10:e28550. [PMID: 38590907 PMCID: PMC10999927 DOI: 10.1016/j.heliyon.2024.e28550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024] Open
Abstract
Background The complexity of calculating the Hijdra score has limited its clinical utility in aiding the diagnosis of intracranial ruptured aneurysms. Objective This study aimed to investigate the diagnostic and prognostic value of the modified Hijdra score in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods Data from 773 patients with subarachnoid hemorrhage (SAH) at the First People's Hospital of Lianyungang from January 2018 to June 2023 were collected. The modified Hijdra scoring method simplifies the assessment of 10 basal cisterns/cisterns fissures compared to the traditional scoring method, with scores ranging from 0 to 2 for each item, and assigns specific scores to hematomas larger than 1 cm in diameter. The data were divided into an evaluation group (n = 641) and a validation group (n = 132). In the evaluation group, the performance of the modified Hijdra score in diagnosis and prognostic prediction was assessed, while the diagnostic and prognostic prediction efficacy of the modified Hijdra method was evaluated using the validation set. Results Among the 641 patients in the evaluation group,550 (85. 8%) were diagnosed with intracranial aneurysms. The modified Hijdra score demonstrated an AUC of 0. 894 for aneurysm diagnosis, with a sensitivity of 98. 0% and a specificity of 64. 8% at a CutOff value of 7. 5. The diagnostic efficacy of the modified Hijdra score was 93. 24%, with a negative predictive value of 84. 29%, while the Hijdra score 's diagnostic efficacy was 85. 34% with a negative predictive value of 48. 89%. The AUC of the modified Hijdra score for predicting prognosis in patients with aneurysms was 0. 824, with a sensitivity of 84. 3% and a specificity of 70. 0% at a CutOff value of 16. 5. In CTA-negative patients, the modified Hijdra score was significantly higher (P < 0. 0001) in patients with aneurysmal SAH (15. 48 ± 3. 93) compared to those with non-aneurysmal SAH (6. 31 ± 4. 52). Conclusions The modified Hijdra score is a valuable tool for assisting in the diagnosis and prognosis prediction of aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Rongjie Wu
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
- Jinzhou Medical University, Liaoning, China
| | - Fangbo Hu
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
- Jinzhou Medical University, Liaoning, China
| | - Changtao Liu
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
| | - Jingshan Liang
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
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Street JS, Pandit AS, Toma AK. Predicting vasospasm risk using first presentation aneurysmal subarachnoid hemorrhage volume: A semi-automated CT image segmentation analysis using ITK-SNAP. PLoS One 2023; 18:e0286485. [PMID: 37262041 DOI: 10.1371/journal.pone.0286485] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/17/2023] [Indexed: 06/03/2023] Open
Abstract
PURPOSE Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) is a significant complication associated with poor neurological outcomes. We present a novel, semi-automated pipeline, implemented in the open-source medical imaging analysis software ITK-SNAP, to segment subarachnoid blood volume from initial CT head (CTH) scans and use this to predict future radiological vasospasm. METHODS 42 patients were admitted between February 2020 and December 2021 to our tertiary neurosciences center, and whose initial referral CTH scan was used for this retrospective cohort study. Blood load was segmented using a semi-automated random forest classifier and active contour evolution implemented in ITK-SNAP. Clinical data were extracted from electronic healthcare records in order to fit models aimed at predicting radiological vasospasm risk. RESULTS Semi-automated segmentations demonstrated excellent agreement with manual, expert-derived volumes (mean Dice coefficient = 0.92). Total normalized blood volume, extracted from CTH images at first presentation, was significantly associated with greater odds of later radiological vasospasm, increasing by approximately 7% for each additional cm3 of blood (OR = 1.069, 95% CI: 1.021-1.120; p < .005). Greater blood volume was also significantly associated with vasospasm of a higher Lindegaard ratio, of longer duration, and a greater number of discrete episodes. Total blood volume predicted radiological vasospasm with a greater accuracy as compared to the modified Fisher scale (AUC = 0.86 vs 0.70), and was of independent predictive value. CONCLUSION Semi-automated methods provide a plausible pipeline for the segmentation of blood from CT head images in aSAH, and total blood volume is a robust, extendable predictor of radiological vasospasm, outperforming the modified Fisher scale. Greater subarachnoid blood volume significantly increases the odds of subsequent vasospasm, its time course and its severity.
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Affiliation(s)
- James S Street
- Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, United Kingdom
| | - Anand S Pandit
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
- High-Dimensional Neurology, Institute of Neurology, University College London, London, United Kingdom
| | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
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Said M, Odensass S, Gümüs M, Rodemerk J, Chihi M, Rauschenbach L, Dinger TF, Darkwah Oppong M, Dammann P, Wrede KH, Sure U, Jabbarli R. Comparing radiographic scores for prediction of complications and outcome of aneurysmal subarachnoid hemorrhage: Which performs best? Eur J Neurol 2023; 30:659-670. [PMID: 36371646 DOI: 10.1111/ene.15634] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE Aneurysmal subarachnoid hemorrhage (aSAH) is characterized by high morbidity and mortality proceeding from the initial severity and following complications of aSAH. Various scores have been developed to predict these risks. We aimed to analyze the clinical value of different radiographic scores for prognostication of aSAH outcome. METHODS Initial computed tomography scans (≤48 h after ictus) of 745 aSAH cases treated between January 2003 and June 2016 were reviewed with regard to Subarachnoid Hemorrhage Early Brain Edema Score (SEBES), and Claassen, Barrow Neurological Institute (BNI), Hijdra, original Graeb and Fisher scale scores. The primary endpoints were development of delayed cerebral ischemia (DCI), in-hospital mortality and unfavorable outcome (modified Rankin Scale score >3) at 6 months after subarachnoid hemorrhage. Secondary endpoints included the different complications that can occur during aSAH. Clinically relevant cutoffs were defined using receiver-operating characteristic curves. The radiographic scores with the highest values for area under the curve (AUC) were included in the final multivariate analysis. RESULTS The Hijdra sum score had the most accurate predictive value and independent associations with all primary endpoints: DCI (AUC 0.678, adjusted odds ratio [aOR] 2.83; p < 0.0001); in-hospital mortality (AUC 0.704, aOR 2.83; p < 0.0001) and unfavorable outcome (AUC 0.726, aOR 2.91; p < 0.0001). Multivariate analyses confirmed the independent predictive value of the radiographic scales for risk of decompressive craniectomy (SEBES and Fisher score), cerebral vasospasm (SEBES, BNI score and Fisher score) and shunt dependency (Hijdra ventricle score and Fisher score) after aSAH. CONCLUSIONS Initial radiographic severity of aSAH was independently associated with occurrence of different complications during aSAH and the final outcome. The Hijdra sum score showed the highest diagnostic accuracy and robust predictive value for early detection of risk of DCI, in-hospital mortality and unfavorable outcome after aSAH.
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Affiliation(s)
- Maryam Said
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Svenja Odensass
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Meltem Gümüs
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Jan Rodemerk
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Karsten Henning Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg Essen, Essen, Germany
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Florez WA, Martinez-Perez R, Deora H, Joaquim AF, García-Ballestas E, Quiñones-Ossa GA, Rivas-Palacios C, Agrawal A, Serrato SA, Jabbour P, Moscote-Salazar LR. An update of predictors of cerebral infarction after aneurysmal subarachnoid hemorrhage: systematic review and meta-analysis. J Neurosurg Sci 2023; 67:1-9. [PMID: 36112119 DOI: 10.23736/s0390-5616.22.05445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Evidence about predictors of poor outcomes such as cerebral infarction (CI) after aneurysmal subarachnoid hemorrhage (aSAH) has not been fully elucidated. EVIDENCE ACQUISITION We performed a systematic review and meta-analysis on studies with adults with aSAH considering RCT and non-RCT, prospective, and retrospective cohort studies describing clinical, imaging as well as angiographic studies in patients with aSAH. EVIDENCE SYNTHESIS After reviewing the complete text, 11 studies were considered eligible, out of which four were ruled out. Degree of clinical severity was the most predictive factor with a higher degree at the presentation on different severity scales being associated with a statistically significant increasing the risk of suffering a CI following aSAH (OR 2.49 [95% CI 1.38-4.49] P=0.0003). Aneurysm size increased the risk of CI (OR 1.49 [95% CI 1.20-1.85] P=0.0003; I2=4%). In six studies analyzed, it was found that an important factor for the subsequent development of CI is vasospasm (OR 7.62 [2.19, 26.54], P=0.0001). CONCLUSIONS The development of vasospasm is a risk factor for CI development after aSAH. In our review, three factors were associated with an increased risk of CI: clinical severity at presentation, vasospasm, and aneurysm size. The major limitation of this meta-analysis is that included studies were conducted retrospectively or were post hoc analyses of a prospective trial.
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Affiliation(s)
- William A Florez
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Faculty of Medicine, Universidad Surcolombiana, Neiva, Colombia
| | - Rafael Martinez-Perez
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.,Division of Neurosurgery, Institute of Neurosciences, Austral University of Chile, Valdivia, Chile
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Andrei F Joaquim
- Department of Neurosurgery. University of Campinas (UNICAMP), São Paulo, Brazil
| | - Ezequiel García-Ballestas
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Gabriel A Quiñones-Ossa
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia - .,Faculty of Medicine, El Bosque University, Bogotá, Colombia
| | - Claudio Rivas-Palacios
- Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | | | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Luis R Moscote-Salazar
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Faculty of Medicine, Universidad Surcolombiana, Neiva, Colombia
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Chalet FX, Briasoulis O, Manalastas EJ, Talbot DA, Thompson JC, Macdonald RL. Clinical Burden of Angiographic Vasospasm and Its Complications After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review. Neurol Ther 2023; 12:371-390. [PMID: 36609962 PMCID: PMC10043150 DOI: 10.1007/s40120-022-00436-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/22/2022] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Angiographic vasospasm (VSP), the narrowing of intracranial arteries, is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and often results in delayed cerebral ischemia (DCI) and cerebral infarction. The objective of this systematic review was to summarize the clinical burden of angiographic VSP and its related complications (DCI and cerebral infarction) after aSAH. METHODS Systematic searches of MEDLINE, Embase, and the Cochrane Library were conducted (in January 2021) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies reporting clinical outcomes of angiographic VSP and its related complications after aSAH. Study outcomes included measures of functional status (modified Rankin Scale [mRS], Glasgow Outcome Scale [GOS], extended Glasgow Outcome Scale [GOS-E], modified Barthel Index, or the modified National Institutes of Health Stroke Scale), cognitive status (Montreal Cognitive Assessment or the Mini Mental State Exam), clinical events (rebleeding), and mortality. Study selection, data extraction, and qualitative analyses were conducted. RESULTS Of 5704 abstracts reviewed, 110 studies were selected: 20 comparative and 39 regression-based studies were included in the qualitative synthesis, 51 descriptive studies were excluded. Most studies (51) were observational and conducted in a single country (53). The occurrence of angiographic VSP and its related complications after aSAH resulted in significantly poorer functional outcomes in three of nine comparative and 11 of 13 regression-based studies, measured by the mRS, and in five of six comparative and eight of nine regression-based studies, measured by the GOS and GOS-E. Angiographic VSP and its related complications were significantly associated with poor cognitive status in all five regression-based studies. Numerically or significantly higher mortality rates in patients with versus those without angiographic VSP and its related complications were reported in five of ten comparative studies and in eight of nine regression-based studies. Six studies looked at specific VSP populations (e.g., by severity or timing of VSP). CONCLUSION Patients with angiographic VSP and its related complications often had poor functional, neurological, and cognitive outcomes and reduced odds of survival both in hospital and at follow-up. We estimate that angiographic VSP and its related complications, DCI and cerebral infarction, lead to an approximately threefold higher odds of poor functional and cognitive outcomes, and about a twofold increase in the odds of death.
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Affiliation(s)
| | - Orestis Briasoulis
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | | | - Darren A Talbot
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | | | - R Loch Macdonald
- Community Health Partners, Community Neurosciences Institute, Fresno, CA, 93701, USA
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Said M, Dinger TF, Gümüs M, Rauschenbach L, Chihi M, Rodemerk J, Lenz V, Oppong MD, Uerschels AK, Dammann P, Wrede KH, Sure U, Jabbarli R. Impact of Anemia Severity on the Outcome of an Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2022; 11:jcm11216258. [PMID: 36362486 PMCID: PMC9657573 DOI: 10.3390/jcm11216258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: Previous reports indicate a negative impact of anemia on the outcome of an aneurysmal subarachnoid hemorrhage (SAH). We aimed to identify the outcome-relevant severity of post-SAH anemia. Methods: SAH cases treated at our institution between 01/2005 and 06/2016 were included (n = 640). The onset, duration, and severity (nadir hemoglobin (nHB) level) of anemia during the initial hospital stay were recorded. Study endpoints were new cerebral infarctions, a poor outcome six months post-SAH (modified Rankin scale > 3), and in-hospital mortality. To assess independent associations with the study endpoints, different multivariable regression models were performed, adjusted for relevant patient and baseline SAH characteristics as well as anemia-associated clinical events during the SAH. Results: The rates of anemia were 83.3%, 67.7%, 40.0%, 15.9%, and 4.5% for an nHB < 11 g/dL, < 10 g/dL, < 9 g/dL, < 8 g/dL, and < 7 g/dL, respectively. The higher the anemia severity, the later was the onset (post-SAH days 2, 4, 5.4, 7.6 and 8, p < 0.0001) and the shorter the duration (8 days, 6 days, 4 days, 3 days, and 2 days, p < 0.0001) of anemia. In the final multivariable analysis, only an nHB < 9 g/dL was independently associated with all study endpoints: adjusted odds ratio 1.7/3.22/2.44 for cerebral infarctions/in-hospital mortality/poor outcome. The timing (post-SAH day 3.9 vs. 6, p = 0.001) and duration (3 vs. 5 days, p = 0.041) of anemia with an nHB < 9 g/dL showed inverse associations with the risk of in-hospital mortality, but not with other study endpoints. Conclusions: Anemia is very common in SAH patients affecting four of five individuals during their hospital stay. An nHB decline to < 9 g/dL was strongly associated with all study endpoints, independent of baseline characteristics and SAH-related clinical events. Our data encourage further prospective evaluations of the value of different transfusion strategies in the functional outcomes of SAH patients.
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Affiliation(s)
- Maryam Said
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
- Correspondence: ; Tel.: +49-201-723-1201; Fax: +49-201-723-5909
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Meltem Gümüs
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Jan Rodemerk
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Veronika Lenz
- Institute of Transfusion Medicine, University Hospital of Essen, 45147 Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Anne-Kathrin Uerschels
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Karsten Henning Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
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9
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Halama D, Merkel H, Werdehausen R, Gaber K, Schob S, Quäschling U, Ziganshyna S, Hoffmann KT, Lindner D, Richter C. Reference Values of Cerebral Artery Diameters of the Anterior Circulation by Digital Subtraction Angiography: A Retrospective Study. Diagnostics (Basel) 2022; 12:2471. [PMID: 36292160 PMCID: PMC9600370 DOI: 10.3390/diagnostics12102471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/10/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022] Open
Abstract
A threshold-based classification of cerebral vasospasm needs reference values for intracranial vessel diameters on digital subtraction angiography (DSA). We aimed to generate adjusted reference values for this purpose by retrospectively analyzing angiograms and potential influencing factors on vessel diameters. Angiograms of the anterior circulation were evaluated in 278 patients aged 18−81 years. The vessel diameters of 453 angiograms (175 bilateral) were gathered from nine defined measuring sites. The effect sizes of physical characteristics (i.e., body weight and height, body mass index, gender, age, and cranial side) and anatomical variations were calculated with MANOVA. Segments bearing aneurysms were excluded for the calculation of reference values. Adjusted vessel diameters were calculated via linear regression analysis of the vessel diameter data. Vessel diameters increased with age and body height. Male and right-sided vessels were larger in diameter. Of the anatomical variations, only the hypoplastic/aplastic A1 segment had a significant influence (p < 0.05) on values of the anterior cerebral artery and the internal carotid artery with a small effect size (|ω2| > 0.01) being excluded from the reference values. We provide gender-, age-, and side-adjusted reference values and nomograms of arterial vessel diameters in the anterior circulation.
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Affiliation(s)
- Dirk Halama
- Department of Oral and Maxillofacial Surgery, University of Leipzig Medical Center, 04103 Leipzig, Germany
| | - Helena Merkel
- Department of Neuroradiology, University of Leipzig Medical Center, 04103 Leipzig, Germany
| | - Robert Werdehausen
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig Medical Center, 04103 Leipzig, Germany
| | - Khaled Gaber
- Department of Neurosurgery, University of Leipzig Medical Center, 04103 Leipzig, Germany
| | - Stefan Schob
- Department of Radiology, Halle University Hospital, 06120 Halle, Germany
| | - Ulf Quäschling
- Department of Radiology, Kantonsspital Baselland, 4410 Liestal, Switzerland
| | - Svitlana Ziganshyna
- Transplant Coordinator Unit, University of Leipzig Medical Center, 04103 Leipzig, Germany
| | - Karl-Titus Hoffmann
- Department of Oral and Maxillofacial Surgery, University of Leipzig Medical Center, 04103 Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University of Leipzig Medical Center, 04103 Leipzig, Germany
| | - Cindy Richter
- Department of Oral and Maxillofacial Surgery, University of Leipzig Medical Center, 04103 Leipzig, Germany
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10
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Merkel H, Lindner D, Gaber K, Ziganshyna S, Jentzsch J, Mucha S, Gerhards T, Sari S, Stock A, Vothel F, Falter L, Quäschling U, Hoffmann KT, Meixensberger J, Halama D, Richter C. Standardized Classification of Cerebral Vasospasm after Subarachnoid Hemorrhage by Digital Subtraction Angiography. J Clin Med 2022; 11:jcm11072011. [PMID: 35407619 PMCID: PMC9000178 DOI: 10.3390/jcm11072011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 02/05/2023] Open
Abstract
Background: During the last decade, cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) was a current research focus without a standardized classification in digital subtraction angiography (DSA). This study was performed to investigate a device-independent visual cerebral vasospasm classification for endovascular treatment. Methods: The analyses are DSA based rather than multimodal. Ten defined points of intracranial arteries were measured in 45 patients suffering from cerebral vasospasm after SAH at three time points (hospitalization, before spasmolysis, control after six months). Mathematical clustering of vessel diameters was performed to generate four objective grades for comparison. Six interventional neuroradiologists in two groups scored 237 DSAs after a new visual classification (grade 0–3) developed on a segmental pattern of vessel contraction. For the second group, a threshold-based criterion was amended. Results: The raters had a reproducibility of 68.4% in the first group and 75.2% in the second group. The complementary threshold-based criterion increased the reproducibility by about 6.8%, while the rating deviated more from the mathematical clustering in all grades. Conclusions: The proposed visual classification scheme of cerebral vasospasm is suitable as a standard grading procedure for endovascular treatment. There is no advantage of a threshold-based criterion that compensates for the effort involved. Automated vessel analysis is superior to compare inter-group results in research settings.
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Affiliation(s)
- Helena Merkel
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Dirk Lindner
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Khaled Gaber
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Svitlana Ziganshyna
- Department of Anaesthesiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany;
| | - Jennifer Jentzsch
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Simone Mucha
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Thilo Gerhards
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Sabine Sari
- Department of Neuroradiology, Giessen University Hospital, Klinikstraße 33, 35392 Giessen, Germany;
| | - Annika Stock
- Department of Neuroradiology, Würzburg University Hospital, Josef-Schneider-Straße 2, 97080 Würzburg, Germany;
| | - Felicitas Vothel
- Department of Radiology and Neuroradiology, Sana Hospital Borna, Rudolf-Virchow-Straße 2, 04552 Borna, Germany;
| | - Lea Falter
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Ulf Quäschling
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Karl-Titus Hoffmann
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Jürgen Meixensberger
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Dirk Halama
- Department of Oral and Maxillofacial Surgery, Leipzig University Hospital, Liebigstraße 12, 04103 Leipzig, Germany;
| | - Cindy Richter
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
- Correspondence: ; Tel.: +49-341-97-20196
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11
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Baulier C, Lessert M, Chauvet JL, Garel P, Bergis A, Burdeau J, Clavier T. Left Ventricular Outflow Tract Obstruction in Patients Treated With Milrinone for Cerebral Vasospasm: Case Report and Literature Review. JMIRX MED 2022; 3:e31019. [PMID: 37463041 PMCID: PMC10337478 DOI: 10.2196/31019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/05/2021] [Accepted: 01/27/2022] [Indexed: 07/20/2023]
Abstract
Subarachnoid hemorrhage is associated with high morbidity and mortality, and cerebral arterial vasospasm is one of its main complications that determines neurological prognosis. The use of intravenous milrinone is becoming more common in the treatment of vasospasm. This molecule has positive inotropic and vasodilating properties by inhibiting phosphodiesterase-3. Its most described side effects are cardiac arrhythmias and arterial hypotension. In this paper, we raise a new issue concerning milrinone and discuss an undescribed side effect of this treatment, left ventricular outflow tract obstruction (LVOTO). Dynamic LVOTO is a clinical situation favored by hypovolemia, decreased left ventricular afterload, and excessive inotropism that can lead to severe hemodynamic failure and pulmonary edema. To our knowledge, this is the first study describing milrinone-induced LVOTO. This could compromise cerebral perfusion and therefore the neurological prognosis of patients. While it is known that catecholamines may induce LVOTO, milrinone-induced LVOTO appears to be a new pathophysiological entity of which neurosurgical intensivists should be aware.
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Affiliation(s)
- Charles Baulier
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Marc Lessert
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | | | - Pauline Garel
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Alexandre Bergis
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Julie Burdeau
- Cardiology Department Rouen University Hospital Rouen France
| | - Thomas Clavier
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
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12
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Marbacher S, Bircher B, Vogt DR, Diepers M, Remonda L, Fandino J. Periinterventional Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage Predicts an Unfavorable Clinical Course. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okaa021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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13
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Agarwal N, Dutta Satyarthee G. Symptomatic Diffuse Vasospasm After Resection of Temporal Ganglioglioma: Review of the Literature with Case Illustration. World Neurosurg 2019; 132:230-235. [PMID: 31505290 DOI: 10.1016/j.wneu.2019.08.239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Symptomatic cerebral vasospasm may occur in the setting of aneurysmal subarachnoid hemorrhage, traumatic brain injury, or after anterior skull base surgery, but its occurrence is extremely rare in the background of glioma surgical resection. CASE DESCRIPTION We present a rare case of symptomatic diffuse vasospasm, which is the fourth reported case of symptomatic vasospasm after temporal lobectomy and the third in the setting of a glial tumor. This patient, a 10-year-old boy, developed bilateral, progressive cerebral infarcts because of diffuse vasospasm after anteromesial temporal lobectomy for a left temporal ganglioglioma leading to significant morbidity. CONCLUSIONS The risk factors, likely pathogenesis and the importance of early diagnosis and timely institution of treatment, in such cases are discussed in the background of relevant literature. The current case represents the first report of symptomatic diffuse vasospasm occuring after surgical resection of intracranial ganglioglioma in the Western literature.
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Affiliation(s)
- Nitish Agarwal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Guru Dutta Satyarthee
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
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14
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Jabbarli R, Pierscianek D, Rölz R, Darkwah Oppong M, Kaier K, Shah M, Taschner C, Mönninghoff C, Urbach H, Beck J, Sure U, Forsting M. Endovascular treatment of cerebral vasospasm after subarachnoid hemorrhage. Neurology 2019; 93:e458-e466. [DOI: 10.1212/wnl.0000000000007862] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/21/2019] [Indexed: 12/20/2022] Open
Abstract
ObjectiveDelayed cerebral ischemia (DCI) is strongly associated with poor outcome after subarachnoid hemorrhage (SAH). Cerebral vasospasm is a major contributor to DCI and requires special attention. To evaluate the effect of vasospasm management on SAH outcome, we performed a pooled analysis of 2 observational SAH cohorts.MaterialsData from 2 institutional databases with consecutive patients with SAH treated between 2005 and 2012 were pooled. The effect of 2 institutional standards of conservative and endovascular vasospasm treatment (EVT) on the rates of DCI (new cerebral infarcts not visible on the post-treatment imaging) and unfavorable outcome (modified Rankin Scale score >2) at 6 months follow-up was analyzed.ResultsThe final analysis included 1,057 patients with SAH. There was no difference regarding demographic (age and sex), clinical (Hunt & Hess grades, acute hydrocephalus, treatment modality, and infections), and radiographic (Fisher grades and aneurysm location) characteristics of the populations. However, there was a significant difference in the rate (24.4% [121/495] vs 14.4% [81/562], p < 0.0001) and timing (first treatment on day 6 vs 8.9 after SAH, p < 0.0001) of EVT. The rates of DCI (20.8% vs 29%, p = 0.0001) and unfavorable outcome (44% vs 50.6%, p = 0.04) were lower in the cohort with more frequent and early EVT. Multivariate analysis confirmed independent effect of EVT standard on DCI risk and outcome.ConclusionsA preventive strategy utilizing frequent and early EVT seems to reduce the risk of DCI in patients with SAH and improve their functional outcome. We recommend prospective evaluation of the value of preventive EVT strategy on SAH.Classification of evidenceThis study provides Class III evidence that for patients with SAH, a frequent and early EVT to treat vasospasm reduces the risk of DCI and improves functional outcome.
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15
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Malinova V, Schatlo B, Voit M, Suntheim P, Rohde V, Mielke D. The impact of temporary clipping during aneurysm surgery on the incidence of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 2018; 129:84-90. [PMID: 28946178 DOI: 10.3171/2017.3.jns162505] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clipping of a ruptured intracranial aneurysm requires some degree of vessel manipulation, which in turn is believed to contribute to vasoconstriction. One of the techniques used during surgery is temporary clipping of the parent vessel. Temporary clipping may either be mandatory in cases of premature rupture (rescue) or represent a precautionary or facilitating surgical step (elective). The aim of this study was to study the association between temporary clipping during aneurysm surgery and the incidence of vasospasm and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) in a large clinical series. METHODS Seven hundred seventy-eight patients who underwent surgical aneurysm treatment after aSAH were retrospectively included in the study. In addition to surgical parameters, the authors recorded transcranial Doppler (TCD) sonography-documented vasospasm (TCD-vasospasm, blood flow acceleration > 120 cm/sec), delayed ischemic neurological deficits (DINDs), and delayed cerebral infarction (DCI). Multivariate binary logistic regression analysis was applied to assess the association between temporary clipping, vasospasm, DIND, and DCI. RESULTS Temporary clipping was performed in 338 (43.4%) of 778 patients during aneurysm surgery. TCD sonographic flow acceleration developed in 370 (47.6%), DINDs in 123 (15.8%), and DCI in 97 (12.5%). Patients with temporary clipping showed no significant increase in the incidence of TCD-vasospasm compared with patients without temporary clipping (49% vs 48%, respectively; p = 0.60). DINDs developed in 12% of patients with temporary clipping and 18% of those without temporary clipping (p = 0.01). DCI occurred in 9% of patients with temporary clipping and 15% of those without temporary clipping (p = 0.02). The need for rescue temporary clipping was a predictor for DCI; 19.5% of patients in the rescue temporary clipping group but only 11.3% in the elective temporary clipping group had infarcts (p = 0.02). Elective temporary clipping was not associated with TCD-vasospasm (p = 0.31), DIND (p = 0.18), or DCI (p = 0.06). CONCLUSIONS Temporary clipping did not contribute to a higher rate of TCD-vasospasm, DIND, or DCI in comparison with rates in patients without temporary clipping. In contrast, there was an association between temporary clipping and a lower incidence of DINDs and DCI. There is no reason to be hesitant in using elective temporary clipping if deemed appropriate.
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Affiliation(s)
- Vesna Malinova
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
| | - Bawarjan Schatlo
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
| | - Martin Voit
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
| | | | - Veit Rohde
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
- 2Department of Neurosurgery, RWTH University, Aachen, Germany
| | - Dorothee Mielke
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
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16
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Jabbarli R, Reinhard M, Roelz R, Kaier K, Weyerbrock A, Taschner C, Scheiwe C, Shah M. Clinical relevance of anterior cerebral artery asymmetry in aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 127:1070-1076. [DOI: 10.3171/2016.9.jns161706] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAn asymmetry of the A1 segments (A1SA) of the anterior cerebral arteries (ACAs) is an assumed risk factor for the development of anterior communicating artery aneurysms (ACoAAs). It is unknown whether A1SA is also clinically relevant after aneurysm rupture. The authors of this study investigated the impact of A1SA on the clinical course and outcome of patients with aneurysmal subarachnoid hemorrhage (SAH).METHODSThe authors retrospectively analyzed data on consecutive SAH patients treated at their institution between January 2005 and December 2012. The occurrence and severity of cerebral infarctions in the ACA territories were evaluated on follow-up CT scans up to 6 weeks after SAH. Moreover, the risk for an unfavorable outcome (defined as > 3 points on the modified Rankin Scale) at 6 months after SAH was assessed.RESULTSA total of 594 patients were included in the final analysis. An A1SA was identified on digital subtraction angiography studies from 127 patients (21.4%) and was strongly associated with ACoAA (p < 0.0001, OR 13.7). An A1SA independently correlated with the occurrence of ACA infarction in patients with ACoAA (p = 0.047) and in those without an ACoAA (p = 0.015). Among patients undergoing ACoAA coiling, A1SA was independently associated with the severity of ACA infarction (p = 0.023) and unfavorable functional outcome (p = 0.045, OR = 2.4).CONCLUSIONSAn A1SA is a common anatomical variation in SAH patients and is strongly associated with ACoAA. Moreover, the presence of A1SA independently increases the likelihood of ACA infarction. In SAH patients undergoing ACoAA coiling, A1SA carries the risk for severe ACA infarction and thus an unfavorable outcome.Clinical trial registration no.: DRKS00005486 (http://www.drks.de/)
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Affiliation(s)
- Ramazan Jabbarli
- Departments of 1Neurosurgery,
- 2Department of Neurosurgery, University Hospital Essen; and
| | - Matthias Reinhard
- 3Department of Neurology and Clinical Neurophysiology, Klinikum Esslingen, Germany
- 4Neurology and Neurophysiology, and
| | | | - Klaus Kaier
- 5Institute for Medical Biometry and Medical Informatics, University Medical Center Freiburg
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17
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Burkhardt JK, Chen X, Winkler EA, Weiss M, Yue JK, Cooke DL, Kim H, Lawton MT. Early Hemodynamic Changes Based on Initial Color-Coding Angiography as a Predictor for Developing Subsequent Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 109:e363-e373. [PMID: 28987853 DOI: 10.1016/j.wneu.2017.09.179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/24/2017] [Accepted: 09/25/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Prediction of vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) remains imperfect and currently relies on clinical and radiographic characteristics. Whether early hemodynamic changes may refine risk stratification for delayed vasospasm (DV) after aSAH was analyzed. METHODS Patients with aSAH (n = 53) and a control group with unruptured intracranial aneurysms (UIA) (n = 12) with initial color-coding angiography at admission were included in this study (n = 65). Clinical and radiologic data were collected, and uni- and multivariate analysis was used to correlate the occurrence of DV (manifesting clinically or detected with transcranial Doppler or angiography) with hemodynamic features of the initial angiography including Tmax and mean transit times (MTTs). RESULTS In the aSAH patient cohort, 37 of 53 patients with aSAH (70%) developed DV. After we controlled for the effects of age, Hunt and Hess grade, and modified Fisher grade, patients with DV had a shorter mean region of interest peak time (Tmax) of the anterior cerebral artery A2 segment (P = 0.036) and the middle cerebral artery M1 (P = 0.045) and M3 (P = 0.013) segments. Mean MTTs between internal carotid artery to middle cerebral artery M3 segment (P = 0.026) was also significantly shorter in patients with DV when compared with controls. CONCLUSIONS Tmax and MTT on angiography within 48 hours of aneurysm rupture before treatment provide an early quantitative assessment in patients with aSAH and in this small study were predictive for the development of subsequent symptomatic DV. Early identification of patients with aSAH at greatest risk of DV may ameliorate clinical outcome through timely, selective implementation of aggressive prophylactic therapy to prevent the effects of DV.
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Affiliation(s)
- Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Xiaolin Chen
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Miriam Weiss
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA; Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
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18
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Al-Mufti F, Amuluru K, Smith B, Damodara N, El-Ghanem M, Singh IP, Dangayach N, Gandhi CD. Emerging Markers of Early Brain Injury and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 107:148-159. [PMID: 28755916 DOI: 10.1016/j.wneu.2017.07.114] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage is characterized by a highly complex pathophysiology and results in neurologic deterioration after the inciting bleed. Despite its significant consequences, prompt diagnosis can be elusive and treatment is often administered too late. Early brain injury, which occurs within the first 72 hours after ictus, may be an important factor for delayed cerebral ischemia and poor overall outcome. Here, we explore the purported clinical and pathologic manifestations of early brain injury to identify biomarkers that could have prognostic value. METHODS We review the literature and discuss potential emerging markers of delayed cerebral ischemia in the context of early brain injury. RESULTS The following clinical features and biomarkers were examined: global cerebral edema, ictal loss of consciousness, ultra early angiographic vasospasm, continuous electroencephalogram monitoring, systemic inflammatory response syndrome, cellular mediators of the inflammatory response, and hematologic derangements. CONCLUSIONS Some of these markers possess independent value for determining the risk of complications after aneurysmal subarachnoid hemorrhage. However, their use is limited because of a variety of factors, but they do provide an avenue of further study to aid in diagnosis and management.
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Affiliation(s)
- Fawaz Al-Mufti
- Division of Neuroendovascular Surgery and Neurocritical Care, Department of Neurology, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA; Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA.
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh, Hamot, Erie, Pennsylvania, USA
| | - Brendan Smith
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Nitesh Damodara
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Mohammad El-Ghanem
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Inder P Singh
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA; Department of Neurology, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Neha Dangayach
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA; Department of Neurology, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA; Department of Neurosurgery, Westchester Medical Center - New York Medical College, Valhalla, New York, USA
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Phan K, Moore JM, Griessenauer CJ, Xu J, Teng I, Dmytriw AA, Chiu AH, Ogilvy CS, Thomas A. Ultra-Early Angiographic Vasospasm After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2017; 102:632-638.e1. [PMID: 28365434 DOI: 10.1016/j.wneu.2017.03.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/10/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE After aneurysmal subarachnoid hemorrhage (aSAH), prognosis is affected heavily by the presence of delayed cerebral ischemia (DCI). There is growing recognition of ultra-early angiographic vasospasm (UEAV) occurring within 48 hours of aSAH; however, its relationship with DCI and ultimately prognosis remains unclear. METHODS Various databases limited to the English language through September 2016 were searched systematically. Eligible studies were those comparing UEAV with control non-UEAV outcomes and follow-up. Two independent reviewers evaluated the quality of studies and abstracted the data, with discrepancies resolved by a third. We calculated odds ratios (ORs) and 95% confidence intervals for all outcomes by using random-effects meta-analyses and performed a heterogeneity analysis. RESULTS Four comparative studies were selected for analysis. Pooled analysis demonstrated that UEAV compared with no-UEAV was associated with greater proportion of rupture aneurysms sized greater than 12 mm (38.3% vs. 24.3%, P < 0.00001). A significantly greater number of patients with UEAV had ruptured MCA aneurysms compared with patients without UEAV (29.7% vs. 19.9%, P = 0.005). Compared with no-UEAV, patients with UEAV were significantly associated with symptomatic cerebral vasospasm (OR 2.07, P = 0.05) and DCI/infarction (OR 2.52, P = 0.02). A significant association also was found between UEAV and an unfavorable outcome at follow-up (OR 1.64, P = 0.03) and greater mortality (OR 2.65, P < 0.00001). CONCLUSIONS UEAV was significantly associated with symptomatic cerebral vasospasm, DCI/infarction, unfavorable outcome at follow-up, and greater mortality. Patients with intracerebral hematoma, intraventricular hemorrhage (Fisher Grade IV), larger ruptured aneurysms >12 mm, and an MCA location were more likely to have UEAV.
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Affiliation(s)
- Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Justin M Moore
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph J Griessenauer
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Xu
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Ian Teng
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Adam A Dmytriw
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Albert H Chiu
- Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital and Community Health Services, Prince of Wales Clinical School, University of New South Wales, Randwick, Australia
| | - Christopher S Ogilvy
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith Thomas
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Ayling OG, Ibrahim GM, Alotaibi NM, Gooderham PA, Macdonald RL. Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage. Stroke 2016; 47:2945-2951. [DOI: 10.1161/strokeaha.116.014794] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/08/2016] [Accepted: 09/21/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Cerebral infarction after aneurysmal subarachnoid hemorrhage is a significant cause of substantial morbidity and mortality. Because early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage may be mediated by different processes, we evaluated whether aneurysm-securing methods contributed to infarcts and whether long-term outcomes differ between early and delayed infarcts.
Methods—
A post hoc analysis of the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) was performed. Using multivariate logistic regression analysis and propensity matching, independent clinical risk factors associated with infarctions were identified, and the contribution of cerebral infarcts to long-term outcomes was evaluated.
Results—
Within the cohort of 413 subjects, early infarcts were present in 76 subjects (18%), whereas delayed infarcts occurred in 79 subjects (19%), and 36 subjects (9%) had new infarctions that were present on both early and delayed imaging. Propensity score matching revealed a significantly higher proportion of early infarcts after clipping (odds ratio, 4.62; 95% confidence interval, 1.99–11.57;
P
=0.00012). Multivariate logistic regressions identified clipping as an independent risk factor for early cerebral infarction (odds ratio, 0.26; 95% confidence interval, 0.15–0.48;
P
<0.001), and angiographic vasospasm was an independent risk factor for delayed cerebral infarction (odds ratio, 1.79; 95% confidence interval, 1.03–3.13;
P
=0.039). Early infarcts were a significant independent risk factor for poor long-term outcomes at 3 months (odds ratio, 2.34; 95% confidence interval, 1.18–4.67;
P
=0.015).
Conclusions—
Clipping is an independent risk factor for the development of early cerebral infarcts, whereas delayed cerebral infarcts are associated with angiographic vasospasm. Early cerebral infarcts are stronger predictors of worse outcome than delayed infarction.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00111085.
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Affiliation(s)
- Oliver G.S. Ayling
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - George M. Ibrahim
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - Naif M. Alotaibi
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - Peter A. Gooderham
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
| | - R. Loch Macdonald
- From the Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (O.G.S.A., G.M.I., N.M.A., R.L.M.); and Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G)
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Conzen C, Schubert GA. About the importance of the acute phase of subarachnoid hemorrhage and the chances for successful translation. J Neurol Sci 2016; 370:310-311. [DOI: 10.1016/j.jns.2016.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 09/19/2016] [Indexed: 10/21/2022]
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Aldakkan A, Mansouri A, Jaja BNR, Alotaibi NM, Macdonald RL. Predictors of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage with Asymptomatic Angiographic Vasospasm on Admission. World Neurosurg 2016; 97:199-204. [PMID: 27717776 DOI: 10.1016/j.wneu.2016.09.096] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/19/2016] [Accepted: 09/23/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Risk of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) with asymptomatic angiographic vasospasm on admission is unclear in the literature. The goal of this study is to identify predictors of clinical DCI in this group of patients. METHODS An exploratory subgroup analysis was conducted in the SAHIT (Subarachnoid Hemorrhage International Trialists) data repository to identify predictors of clinical DCI in patients with good-grade aSAH (World Federation of Neurological Surgeons grade I and II) with angiographic vasospasm on admission. Predictors considered include age, sex, systolic blood pressure at presentation, World Federation of Neurological Surgeon grade, Fisher grade, aneurysm size and location, treatment modality, hydrocephalus requiring external ventricular drain insertion, and severity of vasospasm. The predictors were ranked based on dominance analysis with R2 as fit statistics and assessed in a set of logistic regression analysis models. RESULTS Four data sets out of 16 studies in the SAHIT database were analyzed, with a total of 4125 patients. One hundred and ninety-one patients (4.6%) had asymptomatic angiographic vasospasm at admission. Of those, 78 patients (40.8%) developed clinical DCI. Univariate analysis showed significant associations between severe vasospasm on admission and development of clinical DCI (odds ratio, 9.5, 95% confidence interval, 2.07-43.50; P = 0.004). None of the studied predictors was associated with the development of clinical DCI on multivariate analysis. CONCLUSIONS Asymptomatic angiographic vasospasm in patients with good-grade aSAH on admission is uncommon. Further studies are needed to identify high-risk patients for the development of DCI in the context of asymptomatic early vasospasm.
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Affiliation(s)
- Abdulrahman Aldakkan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada; Division of Neurosurgery, Department of Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Alireza Mansouri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Blessing N R Jaja
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario, Canada
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada; Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario, Canada.
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