Measures and Influencers of Reintegration for the Stroke Patient: A Systematic Review

ABSTRACT

BACKGROUND: Stroke survivors may experience continued difficulties with reintegration, including challenges participating in social roles and performing activities of daily living across settings (eg, home, work). This article assessed the reintegration measures currently used in this clinical population, defining factors that most influence reintegration for these persons. METHODS: A systematic review of PubMed, Scopus, and the Cumulative Index to Nursing and Allied Health Literature databases explored reintegration measures and factors influencing reintegration in stroke populations. Study inclusion criteria for this review were as follows: data-based articles (quantitative and qualitative), studies measuring reintegration or examining outcomes of reintegration, participants being adult stroke populations, and studies published in English. The resulting articles were critically analyzed, and common themes regarding barriers, facilitators, and influencers of reintegration were established. RESULTS: A total of 24 articles met the inclusion criteria and were synthesized for use in this systematic review. Across stroke populations, 13 reintegration tools were used. A few factors, including residual stroke impairments, unmet needs, social support, and sociodemographic characteristics, are currently known to influence reintegration for this population. CONCLUSION: Reintegration must be uniformly defined and measured to best support stroke survivors, and further investigation into influential factors is critical to advance this goal. This review defines current assessments and factors influencing reintegration within stroke populations. Achieving these goals is critical to optimizing reintegration efforts and designing quality-of-life-improving nursing interventions for affected persons.

Long-term neuropsychiatric complications of aneurysmal subarachnoid hemorrhage: a narrative review

This review focuses on the often-neglected long-term neuropsychiatric consequences of aneurysmal subarachnoid hemorrhage (aSAH), beyond traditional randomized trial outcomes of mortality and retreatment. While current guidelines recommend screening for these sequalae, it may not be routinely practiced. This review will underscore the prevalence and management of common neuropsychiatric sequalae, including anxiety, depression, cognitive dysfunction, headaches, seizures, and sexual dysfunction, all of which can significantly impact the quality of life of survivors of aSAH. We emphasize the critical role neurointerventionalists can play by going beyond the customary practice of radiological monitoring for treated aneurysms by screening for and helping guide management of these common neuropsychiatric complications.

Diagnosis and management of subarachnoid haemorrhage

Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.

Remote Ischemic Post-conditioning Reduces Cognitive Impairment in Rats Following Subarachnoid Hemorrhage: Possible Involvement in STAT3/STAT5 Phosphorylation and Th17/Treg Cell Homeostasis

The inflammatory response following subarachnoid hemorrhage (SAH) may lead to Early Brain Injury and subsequently contribute to poor prognosis such as cognitive impairment in patients. Currently, there is a lack of effective strategies for SAH to ameliorate inflammation and improve cognitive impairment in clinical. This study aims to examine the inhibitory impact of remote ischemic post-conditioning (RIPostC) on the body's inflammatory response by regulating Th17/Treg cell homeostasis after SAH. The ultimate goal is to search for potential early treatment targets for SAH. The rat SAH models were made by intravascular puncture of the internal carotid artery. The intervention of RIPostC was administered for three consecutive days immediately after successful modeling. Behavioral experiments including the Morris water maze and Y-maze tests were conducted to assess cognitive functions such as spatial memory, working memory, and learning abilities 2 weeks after successful modeling. The ratio of Th17 cells and Treg cells in the blood was detected using flow cytometry. Immunofluorescence was used to observe the infiltration of neutrophils into the brain. Signal transducers and activators of transcription 5 (STAT5) and signal transducers and activators of transcription 3 (STAT3) phosphorylation levels, receptor-related orphan receptor gamma-t (RORγt), and forkhead box protein P3 (Foxp3) levels were detected by Western blot. The levels of anti-inflammatory factors (IL-2, IL-10, IL-5, etc.) and pro-inflammatory factors (IL-6, IL-17, IL-18, TNF-α, IL-14, etc.) in blood were detected using Luminex Liquid Suspension Chip Assay. RIPostC significantly improved the cognitive impairment caused by SAH in rats. The results showed that infiltration of Th17 cells and neutrophils into brain tissue increased after SAH, leading to the release of pro-inflammatory factors (IL-6, IL-17, IL-18, and TNF-α). This response can be inhibited by RIPostC. Additionally, RIPostC facilitates the transfer of Treg from blood to the brain and triggers the release of anti-inflammatory (IL-2, IL-10, and IL-5) factors to suppress the inflammation following SAH. Finally, it was found that RIPostC increased the phosphorylation of STAT5 while decreasing the phosphorylation of STAT3. RIPostC reduces inflammation after SAH by partially balancing Th17/Treg cell homeostasis, which may be related to downregulation of STAT3 and upregulation of STAT5 phosphorylation, which ultimately alleviates cognitive impairment in rats. Targeting Th17/Treg cell homeostasis may be a promising strategy for early SAH treatment.

Safety and functional outcome analysis of ventriculoperitoneal shunt placement for hydrocephalus within the critical phase of possible delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

Shunt-dependent hydrocephalus (HC) is a common sequela following aneurysmal subarachnoid hemorrhage (aSAH). However, there is still poor evidence regarding the optimal timing of ventriculoperitoneal shunt (VPS) placement, particularly in the context of early aSAH-associated complications such as delayed cerebral ischemia (DCI). The purpose of this study was to compare the impact of early (< 21 days after aSAH) versus late (≥ 21 days after aSAH) VPS placement on the functional clinical outcome. We retrospectively analyzed data from 82 patients with VPS placement after aSAH enrolled in our institutional database between 2011 and 2021. We compared two groups, early VPS placement (< 21 days after aSAH) versus late VPS placement (≥ 21 days after aSAH) in terms of demographics, SAH grading, radiological parameters, externalized cerebrospinal fluid diversions, DCI, VPS variables, and functional outcome. We identified 53 patients with early and 29 patients with late VPS implantation. Baseline variables, such as the modified Rankin Scale (mRS), the World Federation of Neurological Surgeons Scale, the Glasgow Coma Scale, and Fisher grade were not significantly different between the groups. Postoperatively, the mRS (p = 0.0037), the Glasgow Outcome Scale (p = 0.0037), and the extended Glasgow Outcome Scale (p = 0.0032) showed significantly better functional results in patients with early cerebrospinal fluid diversion. The rate of DCI did not differ significantly between the groups (p = 0.53). There was no difference in the rate of VPS placement associated complications (p = 0.44) or overall mortality (p = 0.39). Early shunt implantation, within 21 days after aSAH and therefore during the timeframe of possible DCI, might not be harmful in patients developing HC after aSAH.

Depression screening in patients with aneurysmal subarachnoid haemorrhage and their caregivers: A systematic review

BACKGROUND

Depression commonly occurs after aneurysmal subarachnoid haemorrhage (aSAH) which can negatively impact patients and their caregivers. Identification and validation of depression screening instruments specifically for patients with aSAH and their caregivers has not been performed.

OBJECTIVES

The objectives of this study were to identify the common depression screening tools in patients with aSAH and their caregivers and to determine if they are validated for use in these populations.

METHODS

Medical Subject Headings and keyword search terms were used in five electronic databases to identify randomised controlled, quasi-experimental and observational studies published between 1 January 2010 and 26 June 2022. Screening, data extraction and study quality assessments were conducted by two independent reviewers.

RESULTS

Of the 3440 identified studies, 61 met inclusion, with 2 of 61 (3%) RCTs, 2 of 61 (3%) quasi-experimental, and 57 of 61 (93%) observational studies included. The majority of studies (58/61 [95%]) reported patient-only depression screening, 1 of 61 (2%) reported both patients' and caregivers' depression screening, and 2 of 61 (3%) reported caregiver-only depression screening. Nine depression screening instruments were identified. The Beck Depression Inventory-II (BDI-II) was the most commonly used (13/59; 22%), followed by the Hospital Anxiety and Depression Scale (HADS) (12/59; 20%). In the ischaemic stroke population, the BDI-II was reported to have excellent sensitivity (0.85) and specificity (0.75); the HADS was also found to have good sensitivity (0.62) and specificity (0.83) in the ischaemic stroke population. Only two depression screening instruments for caregivers were identified: HADS and Goldberg Depression Scale. Both were found to have good sensitivity (>0.80) and specificity (>0.80) in the general population.

CONCLUSION

The BDI-II and HADS were the most commonly used depression screening instruments in patients with aSAH. Neither of these instruments has been specifically validated in an aSAH population. None of the nine depression instruments were validated for patients with aSAH. Due to an insufficient number of studies in caregivers' population, validity was unable to be determined.

Return to work for adults following stroke: a scoping review of interventions, factors, barriers, and facilitators

OBJECTIVE

This scoping review aimed to map the literature on interventions, factors, barriers, and facilitators for return to work for adults post-stroke with or without communication disorders.

INTRODUCTION

Difficulties in returning to work can significantly impact individuals following a stroke (eg, their sense of purpose and self-esteem), not only financially, but also as they adjust to the change in their situation. Such difficulties may arise from communication disorders as well as physical impairments. Previous reviews on return to work post-stroke have focused on specific aspects, such as interventions, or barriers and facilitators, but have not provided a comprehensive map of the field. Further, no systematic or scoping reviews to date have focused on literature addressing return to work for people with communication disorders post-stroke.

INCLUSION CRITERIA

This review considered literature that reported on interventions, barriers, and facilitators for return to work for adults (aged 16 years or older) following an ischemic or hemorrhagic stroke. Records focusing on transient ischemic attacks or acquired brain injury were excluded, as were those in which a comorbidity or disability (eg, learning disability, dementia, respiratory disorder) had a significant impact on the individual's ability to work.

METHODS

This review followed the JBI scoping review methodology. Primary research of any type, systematic and non-systematic reviews, and gray literature from developed countries written in English from 2010 to the present day were identified from 7 databases, 2 gray literature repositories, JBI Evidence Synthesis , and an internet search. Records were screened for relevance to the review topic by 2 independent reviewers, and data relevant to the review questions were extracted. Findings were presented as narrative supported by tables.

RESULTS

Of the 106 sources included, 61 addressed demographic-based, socioeconomic-based, impairment-based, or recovery-based factors related to return to work. One of these 61 sources, a narrative review, focused on communication disorders. Thirty-eight sources explored barriers and facilitators for return to work from different stakeholders' perspectives; 3 of these 38 sources, including 2 qualitative studies and 1 narrative review, focused on post-stroke communication disorders. Eleven sources focused on interventions, including 7 studies (reported across 9 sources) that developed or tested return-to-work interventions. Of these primary studies, 1 randomized controlled trial and 1 retrospective cohort study were identified. The remaining intervention studies were case studies or case series. None of these intervention studies addressed communication disorders.

CONCLUSIONS

While there has been extensive research on factors, barriers, and facilitators for return to work post-stroke, there is a lack of research on interventions supporting return to work. There is also a significant gap in the evidence base on returning to work with a post-stroke communication disorder, highlighting the need for further research in this important area.

"My head feels like it has gone through a mixer" - a qualitative interview study on recovery 1 year after aneurysmal subarachnoid hemorrhage

PURPOSE

To describe patients' perceived and expected recovery 1 year after aneurysmal subarachnoid hemorrhage (aSAH).

MATERIALS AND METHODS

Semi-structured interviews were conducted with 16 persons 1 year after aSAH. Inductive manifest qualitative content analysis was used.

RESULTS

The analysis resulted in two categories and seven subcategories. The category "A spectrum of varying experiences of recovery" includes four subcategories describing physical recovery, mental recovery, alterations in social life, and perceived possibilities to return to normality. Some informants felt that life was almost as before, while others described a completely different life, including a new view of self, altered relationships, not being able to return to work, and effects on personal finances. The category "A spectrum of reflections and expectations of recovery" comprises three subcategories depicturing that expectations of recovery were influenced by existential thoughts, describing what they based own expectations of recovery on, and how expectations from others influenced them.

CONCLUSIONS

aSAH was perceived as a life-changing event. The changes impacted on informants' view of self and relationships, and they perceived new barriers in their living conditions. Lack of information on expected recovery was expressed and expectations of recovery were at times unrealistic.IMPLICATIONS FOR REHABILITATIONContracting an aneurysmal subarachnoid hemorrhage (aSAH) is a life-changing event with possible impact on a variety of areas in daily life.There is a need for improved information to aSAH survivors and their significant others on the course of the recovery and possible long-term consequences.aSAH survivors may need assistance to balance unrealistic expectations on recovery.

Trimethylamine N-oxide (TMAO) in patients with subarachnoid hemorrhage: a prospective observational study

BACKGROUND

It is suspected that microbiome-derived trimethylamine N-oxide (TMAO) may enhance platelet responsiveness and accordingly be thrombophilic. The purpose of this prospective observational study is to evaluate TMAO in patients with subarachnoid hemorrhage (SAH) and compare it with a control group. A secondary aim was to investigate TMAO in the cerebrospinal fluid (CSF) from SAH patients. This should provide a better understanding of the role of TMAO in the pathogenesis of SAH and its thrombotic complications.

METHODS

The study included patients with diagnosed spontaneous SAH recruited after initial treatment on admission and patients with nerve, nerve root, or plexus disorders serving as controls. Blood samples were gathered from all patients at recruitment. Additionally, sampling of SAH patients in the intensive care unit continued daily for 14 days. The CSF was collected out of existing external ventricular drains whenever possible.

RESULTS

Thirty-four patients diagnosed with SAH, and 108 control patients participated in this study. Plasma TMAO levels at baseline were significantly lower in the SAH group (1.7 μmol/L) compared to the control group (2.9 μmol/L). TMAO was detectable in the CSF (0.4 μmol/L) and significantly lower than in plasma samples of the SAH group at baseline. Plasma and CSF TMAO levels correlated positively. The TMAO levels did not differ significantly during the observation period of 15 days.

CONCLUSIONS

Although we assumed that patients with higher TMAO levels were at higher risk for SAH a priori, plasma TMAO levels were lower in patients with SAH compared with control subjects with nerve, nerve root, or plexus disorders on admission to the hospital. A characteristic pattern of plasma TMAO levels in patients with SAH was not found.

External ventricular drain use is associated with functional outcome in aneurysmal subarachnoid hemorrhage

Purpose

External ventricular drains (EVD) are commonly used in aneurysmal subarachnoid hemorrhage (aSAH) patients and can be life-saving by diverting cerebrospinal fluid. However, the overall relationship between EVD use and outcome is poorly understood.

Methods

In an exploratory analysis of an aSAH patient cohort, we examined EVD use in relation to modified Rankin Scale (mRS) at hospital discharge and at 6 months (unfavorable outcome = mRS > 2) using univariable and multivariable analyses.

Results

EVDs were placed in 31 of 56 (55.4%) patients and more often in women than men (66.7% vs 35.0%, p = 0.022) despite similar rates of hydrocephalus. Women had greater ICU [18 (13.5–25) vs 11.5 (6.5–18.5) days, p = 0.014] and hospital lengths of stay (LOS) [20.5 (16.5–34) vs 13.5 (10.5–27) days, p = 0.015] than men and greater mRS at discharge [4 (3–5) vs 3 (2–3.5), p = 0.011] although mRS at 6 months was similar. Patients with EVDs had longer ICU and hospital LOS and greater mRS at discharge [5 (3–6) vs 2 (2–3), p < 0.001] and at 6 months [4 (2–6) vs 1 (0–2), p = 0.001] than those without an EVD. In multivariable models, EVD use was associated with unfavorable 6-month outcome accounting for age, sex, and admission modified Fisher scale, but not in models adjusting for Hunt and Hess scale and World Federation of Neurological Surgeons scale.

Conclusion

In an aSAH cohort, the use of EVDs was associated with female sex and longer LOS, and may be linked to functional outcomes at discharge and at 6 months, although these associations warrant further investigation.

Duration and characteristics of persistent headache following aneurysmal subarachnoid hemorrhage

OBJECTIVE

To assess the long-term frequency, prognosis, and phenotype of persistent headache following aneurysmal subarachnoid hemorrhage (aSAH).

BACKGROUND

Very little is known about long-term headache following aSAH with no studies looking beyond 3 years.

METHODS

Retrospective analysis comparing aSAH cases to matched controls in the UK Biobank, a prospective cohort study. Headache frequency and phenotype were compared using group comparison tests. The relationship between headache frequency and time was assessed using correlation analysis.

RESULTS

Headache was more frequent following aSAH (aSAH: 258/864 [29.9%] vs. controls: 666/3456 [19.3%], χ²  = 45.5, p < 0.001) at a median follow-up of 7.5 years. Headache frequency decreased over time (R_S  = -0.71, p = 0.028), affecting 29/58 (50%) patients in the first year and reducing to 13/47 (28%) patients 10 years later. Headache frequency was not related to aSAH severity (z = 0.249, p = 0.803), treatment (z = 0.583, p = 0.560), or hydrocephalus (z = -1.244, p = 0.214). There was a consistently higher frequency of migrainous features following aSAH compared to controls, although this did not reach statistical significance.

CONCLUSIONS

Persistent headache is more frequent following aSAH compared to controls in the long term and the prevalence reduces gradually over time. The increased frequency of migrainous features suggests that selected patients with post-aSAH headache may benefit from migraine treatment.

Long-term outcomes after aneurysmal subarachnoid hemorrhage: A prospective observational cohort study

OBJECTIVES

The survival rates for patients affected by aneurysmal subarachnoid hemorrhage (aSAH) have increased in recent years; however, many patients continue to develop cognitive dysfunctions that affect their quality of life. The commonly used outcome measures often fail to identify these cognitive dysfunctions. This study aimed to evaluate the long-term outcomes at 1 and 3 years after aSAH to assess changes over time and relate outcomes to patient characteristics and events during the acute phase.

MATERIALS AND METHODS

This prospective observational study included patients that experienced aSAH. Patients were assessed according to the extended Glasgow Outcome Scale, Life Satisfaction Questionnaire, Mayo-Portland Adaptability inventory-4, and Mental Fatigue scale.

RESULTS

Patients were assessed after 1 year (n = 62) and 3 years (n = 54). At 3 years, the extended Glasgow Outcome Scale score improved in 15% and worsened in 12% of the patients. Mental fatigue was observed in 57% of the patients at 1 year. Patients <60 years of age at the time of aSAH had more self-assessed problems, including pain/headache (p < .01), than patients >60 years of age. Patients with delayed cerebral ischemia during the acute phase reported more dissatisfaction at 3 years, whereas no significant result was seen at 1 year.

CONCLUSIONS

Cognitive dysfunction, especially mental fatigue, is common in patients with aSAH, which affects quality of life and recovery. Patient outcome is a dynamic process developing throughout years after aSAH, involving both improvement and deterioration. This study indicates the importance of longer follow-up periods with broad outcome assessments.

Association of Rebleeding and Delayed Cerebral Ischemia with Long-term Mortality Among 1-year Survivors After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND AND OBJECTIVE

The potential impact of rebleeding and Delayed Cerebral Ischemia (DCI) on long-term survival in patients with aneurysmal subarachnoid hemorrhage (aSAH) remained unclear. This study aimed to investigate whether DCI and rebleeding increase the risk of long-term all-cause mortality in patients with aSAH who survived the follow-up period of one year.

METHODS

We retrospectively collected data on patients with atraumatic aSAH who were still alive 12 months after aSAH occurrence between December 2013 and June 2019 from the electronic health system. Patients were then classified by the occurrence of rebleeding or DCI during hospitalization. Death records were obtained from an administrative database, the Chinese Household Registration Administration System, until April 20, 2021. Multivariable Cox proportional hazards models were used to compare overall survival in different groups. Sensitivity analysis was performed with propensity-score matching (PSM).

RESULTS

A total of 2,607 patients were alive one year after aSAH. The crude annual death rate from any cause among patients who had rebleeding (7.2 per 100 person-years) and patients who had DCI (3.7 per 100 person-years) during hospitalization was higher than that of patients with neither event (2.1 per 100 person-years). Multivariate analysis showed that rebleeding is an independent risk factor for long-term mortality (adjusted hazard ratio (aHR), 2.37; 95% confidence interval (CI), 1.47- 3.81). DCI was an independent prognostic factor of poorer overall survival (aHR, 2.09; 95% CI, 1.54-2.84).

CONCLUSION

Amongst patients alive one year after aSAH, rebleeding and DCI during hospitalization were independently associated with higher rates of long-term mortality.

Amantadine treatment is associated with improved consciousness in patients with non-traumatic brain injury

OBJECTIVE

This study determined the effect of amantadine treatment on consciousness in patients with non-traumatic brain injury.

METHODS

We pooled individual patient data of five single-centre observational studies to determine the effect of amantadine treatment among patients with ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, community-acquired bacterial meningitis and status epilepticus, admitted between January 2012 and December 2015 and ventilated ≥7 days. Patient selection and multivariable regression modelling were used to adjust for differences in intergroup comparison and for parameters associated with consciousness. Improvement of consciousness 5 days after treatment initiation was defined as primary outcome. Secondary outcomes included Glasgow Coma Scale (GCS) at day 5 and GCS at day 10, rate of ICU delirium, epileptic seizures and all-cause mortality at 90 days.

RESULTS

Overall, 84 of 294 (28.6%) eligible patients received amantadine. Amantadine treatment was associated with improvement of consciousness at day 5 (amantadine: 86.9% vs control: 54.0%; absolute difference: 32.9 (20.0-44.2); adjusted OR (aOR): 5.71 (2.50-13.05), p<0.001). Secondary outcomes showed differences in GCS 5 days (9 (8-11) vs 6 (3-9), p<0.001) and GCS 10 days (10(8-11) vs 9(6-11),p=0.003) after treatment initiation. There were no significant differences regarding all-cause mortality (aOR: 0.89 (0.44-1.82), p=0.758) and ICU delirium (aOR: 1.39 (0.58-3.31), p=0.462). Rate of epileptic seizures after initiation of amantadine treatment was numerically higher in the amantadine group (amantadine: 10.7% vs control: 3.0%; absolute difference: 7.7 (0.3-16.4); aOR: 3.68 (0.86-15.71), p=0.079).

CONCLUSIONS

Amantadine treatment is associated with improved consciousness among patients with different types of non-traumatic brain injury in this observational cohort analysis. Epileptic seizures should be considered as potential side effects and randomised controlled trials are needed to confirm these findings.

Severe headache trajectory following aneurysmal subarachnoid hemorrhage: the association with lower sodium levels

BACKGROUND

A clinical hallmark of aneurysmal SAH (aSAH) is headache. Little is known about post-aSAH headache factors which may point to underlying mechanisms. In this study, we aimed to characterize the severity and trajectory of headaches in relation to clinical features of patients with aSAH.

METHODS

This is a retrospective longitudinal study of adult patients admitted to an academic tertiary care center between 2012 and 2019 with aSAH who could verbalize pain scores. Factors recorded included demographics, aneurysm characteristics, analgesia, daily morning serum sodium concentration, and occurrence of vasospasm. Group-based trajectory modeling was used to identify headache pain trajectories, and clinical factors were compared between trajectories.

RESULTS

Of 91 patients included in the analysis, mean age was 57 years and 20 (22%) were male. Headache score trajectories clustered into two groups: patients with mild-moderate and moderate-severe pain. Patients in the moderate-severe pain group were younger (P<0.05), received more opioid analgesia (P<0.001), and had lower sodium concentrations (P<0.001) than patients in the mild-moderate pain group.

CONCLUSION

We identified two distinct post-aSAH headache pain trajectory cohorts and identified an association with age, analgesia, and sodium levels. Future prospective studies considering sodium homeostasis and volume status under standardized analgesic regimens are warranted.

XGBoost Machine Learning Algorithm for Prediction of Outcome in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Patients suffered aneurysmal subarachnoid hemorrhage (aSAH) usually develop poor survival and functional outcome. Evaluating aSAH patients at high risk of poor outcome is necessary for clinicians to make suitable therapeutical strategy. This study is conducted to develop prognostic model using XGBoost (extreme gradient boosting) algorithm in aSAH.

METHODS

A total of 351 aSAH patients admitted to West China hospital were identified. Patients were divided into training set and test set with ratio of 7:3 to testify the predictive value of XGBoost based prognostic model. Additionally, logistic regression model was also constructed and compared with XGBoost based model. Area under the receiver operating characteristic curve (AUC), sensitivity and specificity were calculated to evaluate the value of XGBoost and logistic regression.

RESULTS

There were 74 (21.1%) non-survivors and 148 (42.1%) patients with unfavorable functional outcome. Non-survivors had older age (p=0.025), lower Glasgow coma scale (GCS) (p<0.001), higher World Federation of Neurosurgical Societies WFNS score (p<0.001), mFisher score (p<0.001). The incidence of intraventricular hemorrhage (IVH) (p=0.025) and delayed cerebral ischemia (DCI) (p<0.001) was higher in non-survivors than survivors. The AUC of XGBoost model for predicting mortality and unfavorable functional outcome were 0.950 and 0.958, which were higher than 0.767 and 0.829 of logistic regression model.

CONCLUSION

XGBoost based model is more precise than logistic regression model in predicting outcome of aSAH patients. Using XGBoost prognostic model is helpful for clinicians to identify high-risk aSAH patients and therefore strengthen medical care.

Subarachnoid Hemorrhage

PURPOSE OF REVIEW

Subarachnoid hemorrhage (SAH) remains an important cause of mortality and long-term morbidity. This article uses a case-based approach to guide readers through the fundamental epidemiology and pathogenesis of SAH, the approach to diagnosis and management, the results of clinical trials and evidence to date, prognostic considerations, controversies, recent developments, and future directions in SAH.

RECENT FINDINGS

Historically, management of SAH focused on prevention and treatment of subsequent cerebral vasospasm, which was thought to be the primary cause of delayed cerebral ischemia. Clinical and translational studies over the past decade, including several therapeutic phase 3 randomized clinical trials, suggest that the pathophysiology of SAH-associated brain injury is multiphasic and multifactorial beyond large vessel cerebral vasospasm. The quest to reduce SAH-associated brain injury and improve outcomes is shifting away from large vessel cerebral vasospasm to a new paradigm targeting multiple brain injury mechanisms, including early brain injury, delayed cerebral ischemia, microcirculatory dysfunction, spreading cortical depolarization, inflammation, and the brain-body interaction in vascular brain injury with critical illness.Despite multiple negative randomized clinical trials in search of potential therapeutic agents ameliorating the downstream effects after SAH, the overall outcome of SAH has improved over recent decades, likely related to improvements in interventional options for ruptured cerebral aneurysms and in critical care management. Emerging clinical evidence also suggests potential harmful impact of historic empiric treatments for SAH-associated vasospasm, such as prophylactic induction of hypertension, hypervolemia, and hemodilution (triple H therapy).With decreasing mortality, long-term SAH survivorship and efforts to reduce chronic morbidity and to improve quality of life and patient-centered outcome are growing areas of unmet need. Despite existing guidelines, significant variabilities in local and regional practices and in scientific terminologies have historically limited advancement in SAH care and therapeutic development. Large global collaborative efforts developed harmonized SAH common data elements in 2019, and studies are under way to examine how existing variabilities in SAH care impact long-term SAH outcomes.

SUMMARY

Although the overall incidence and mortality of SAH is decreasing with advances in preventive and acute care, SAH remains a major cause of long-term morbidity in survivors. Significant variabilities in care settings and empiric treatment protocols and inconsistent scientific terminologies have limited advancement in patient care and therapeutic clinical studies. Large consensus efforts are under way to introduce clinical guidelines and common data elements to advance therapeutic approaches and improve patient outcome.

Prognostic Factors in Neurorehabilitation of Stroke: A Comparison among Regression, Neural Network, and Cluster Analyses

There is a large body of literature reporting the prognostic factors for a positive outcome of neurorehabilitation performed in the subacute phase of stroke. Despite the recent development of algorithms based on neural networks or cluster analysis for the identification of these prognostic factors, the literature lacks a rigorous comparison among classical regression, neural network, and cluster analysis. Moreover, the three methods have rarely been tested on a sample independent from that in which prognostic factors have been identified. This study aims at providing this comparison on a wide sample of data (1522 patients) and testing the results on an independent sample (1000 patients) using 30 variables. The accuracy was similar among regression, neural network, and cluster analyses on the analyzed sample (76.6%, 74%, and 76.1%, respectively), but on the test sample, the accuracy of neural network decreased (70.1%). The three models agreed in identifying older age, severe impairment, unilateral spatial neglect, and total anterior circulation infarcts as important prognostic factors. The binary regression analysis also provided solid results in the test sample, especially in terms of specificity (81.8%). Cluster analysis also showed a high sensitivity in the test sample (82.6%) and allowed a meaningful easy-to-use classification tree to be obtained.

Beyond Functional Impairment: Redefining Favorable Outcome in Patients with Subarachnoid Hemorrhage

BACKGROUND

For outcome assessment in patients surviving subarachnoid hemorrhage (SAH), the modified Rankin scale (mRS) represents the mostly established outcome tool, whereas other dimensions of outcome such as mood disorders and impairments in social life remain unattended so far.

OBJECTIVE

The aim of our study was to correlate 12-month functional and subjective health outcomes in SAH survivors.

METHODS

All SAH patients treated over a 5-year period received outcome assessment at 12 months, including functional scores (mRS and Barthel Index [BI]), subjective health measurement (EQ-5D), and whether they returned to work. Analyses - including utility-weighted mRS - were conducted to detect associations and correlations among different outcome measures, especially in patients achieving good functional outcome (i.e., mRS 0-2) at 12 months.

RESULTS

Of 351 SAH survivors, 287 (81.2%) achieved favorable functional outcome at 12 months. Contrary to the BI, the EQ-5D visual analog scale (VAS) showed a strong association with different mRS grades, accentuated in patients with favorable functional outcome. Despite favorable functional outcome, patients reported a high rate of impairments in activities (24.0%), pain (33.4%), and anxiety/depression (42.5%). Further, multivariable analysis revealed (i) impairments in activities (odds ratio [OR] [95% confidence interval {CI}]: 0.872 [0.817-0.930]), (ii) presence of depression or anxiety (OR [95% CI]: 0.836 [0.760-0.920]), and (iii) return to work (OR [95% CI]: 1.102 [0.1.013-1.198]) to be independently associated with self-reported subjective health.

CONCLUSION

Established stroke scores mainly focusing on functional outcomes do poorly reflect the high rate of subjective impairments reported in SAH survivors, specifically in those achieving good functional outcome. Further studies are needed to investigate whether psychoeducational approaches aiming at improving coping mechanisms and perceived self-efficacy may result in higher subjective health in these patients.

Harnessing cerebrospinal fluid circulation for drug delivery to brain tissues

Initially thought to be useful only to reach tissues in the immediate vicinity of the CSF circulatory system, CSF circulation is now increasingly viewed as a viable pathway to deliver certain therapeutics deeper into brain tissues. There is emerging evidence that this goal is achievable in the case of large therapeutic proteins, provided conditions are met that are described herein. We show how fluid dynamic modeling helps predict infusion rate and duration to overcome high CSF turnover. We posit that despite model limitations and controversies, fluid dynamic models, pharmacokinetic models, preclinical testing, and a qualitative understanding of the glymphatic system circulation can be used to estimate drug penetration in brain tissues. Lastly, in addition to highlighting landmark scientific and medical literature, we provide practical advice on formulation development, device selection, and pharmacokinetic modeling. Our review of clinical studies suggests a growing interest for intra-CSF delivery, particularly for targeted proteins.

Pterygopalatine Fossa Blockade as Novel, Narcotic-Sparing Treatment for Headache in Patients with Spontaneous Subarachnoid Hemorrhage

BACKGROUND

Severe headache is a hallmark clinical feature of spontaneous subarachnoid hemorrhage (SAH), affecting nearly 90% of patients during index hospitalization, regardless of the SAH severity or presence of a culprit aneurysm. Up to 1 in 4 survivors of SAH experience chronic headaches, which may be severe and last for years. Data guiding the optimal management of post-SAH headache are lacking. Opioids, often in escalating doses, remain the guideline-recommended mainstay of acute therapy, but pain relief remains suboptimal.

METHODS

This study is a case series of adult patients who received bilateral pterygopalatine fossa (PPF) blockade for the management of refractory headaches after spontaneous SAH (aneurysmal and non-aneurysmal) at a single tertiary care center. We examined pain scores and analgesic requirements before and after block placement.

RESULTS

Seven patients (median age 54 years, 3 men, four aneurysmal and three non-aneurysmal) received a PPF-block between post-bleed day 6-11 during index hospitalization in the neurointensive care unit. The worst pain recorded in the 24-h period before the block was significantly higher than in the period 4 h after the block (9.1 vs. 3.1; p = 0.0156), and in the period 8 h after the block (9.1 vs. 2.8; p = 0.0313). The only complication was minor oozing from the needle insertion sites, which subsided completely with gauze pressure within 1 min.

CONCLUSIONS

PPF blockade might constitute a promising opioid-sparing therapeutic strategy for the management of post-SAH headache that merits further prospective controlled randomized studies.