2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

Pain Assessment Following Opioid Administration in Aneurysmal Subarachnoid Hemorrhage Associated Headache

Background: Headache is a debilitating complication following an aneurysmal subarachnoid hemorrhage (aSAH). Despite its impact on morbidity and quality of life, limited evidence characterizes the effectiveness of opioids. Objective: The aim of this study was to evaluate opioid associated reduction in pain scores in patients with aSAH-associated headache. Methods: This is a retrospective study of adult patients with an aSAH, Hunt and Hess grades I - III, admitted to a neurosciences intensive care unit. Descriptive and inferential statistics were used to characterize headache treatment strategies and opioid associated reduction in pain scores. Results: Opioids were used in up to 97.6% of patients for the management of aSAH-associated headache. Median reduction in pain after opioid administration was -1 (IQR: -3-0). Correlation between opioid dose and change in pain scores was negligible (rs = .01). Overall, 68.8% of patients were discharged on an opioid analgesic with predictive factors being severe headache (OR 2.52; 1.04 - 6.14) and oral morphine milligram equivalents ≥60 mg per day during the hospital stay (OR 3.02; 1.22 - 7.47). Conclusions: Opioids were associated with a small reduction in pain when assessed via the NRS. An increased opioid dose did not correlate with a greater reduction in assessed pain scores. A high percentage of patients remained on opioids throughout hospitalization and were eventually discharged on an opioid. The impact of discharge opioid prescriptions and risk of opioid persistence creates a cause for concern. It is imperative that we seek improved pain management strategies for aSAH-associated headache.

Quantitative analysis of HSV‑1 shedding as a predictor of cerebral vasospasm severity in patients with subarachnoid hemorrhage

Cerebral vasospasm (CV) is a critical determinant of outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). Despite advances in neurocritical care, modifiable risk factors for CV remain poorly understood, and identifying them could significantly enhance patient management and treatment strategies. The present study explored the potential link between the reactivation of herpes simplex virus type 1 (HSV-1), a common resident virus in cranial nerves, and CV severity. It was hypothesized that higher HSV-1 viral load in saliva may be associated with increased CV severity. Saliva samples were collected on days 4, 7, 10 and 14 post-aSAH, and HSV-1 DNA levels were measured using quantitative PCR. CV severity was assessed using the Lindegaard ratio (LR), with an LR >3 considered the diagnostic threshold for CV. A total of 36 patients were enrolled, and 139 saliva samples were collected. HSV-1 DNA was detected in 19.4% of samples (27/139), and 44% of patients (16/36) developed CV. HSV-1 seropositive patients made up 88.9% (32/36) of the cohort, with 50% exhibiting viral shedding during the study period. None of the HSV-1 seronegative patients (11.1%, 4/36) exhibited viral shedding or developed CV. Regression analysis showed a positive association between HSV-1 viral load and CV severity, with viral load explaining 27.8% of the variability (P=0.005). Age was also significant, with older patients experiencing less severe CV (P<0.001). Supervised machine learning identified viral load thresholds that aligned with standard LR values for moderate and severe CV. While the small sample size and observational design limit the generalizability of the results, these findings suggested that earlier detection and intervention for CV could be informed by assessing HSV-1 serostatus and monitoring viral activity through saliva samples or other non-invasive methods, highlighting the need for larger, controlled studies to validate these results.

Endovascular treatment of ruptured basilar artery trunk aneurysms: complications and long-term outcomes

OBJECT

Treatment of ruptured basilar artery trunk (BAT) aneurysms is challenging, and is associated with high complication and mortality rates. Herein, we analyzed the complications, long-term outcomes, and outcome predictors of endovascular treatment for ruptured BAT aneurysms.

METHODS

Between January 2011 and July 2023, 36 patients with 36 ruptured BAT aneurysms underwent endovascular treatment at our institution. The postprocedural complications and clinical and angiographic outcomes were subsequently reviewed, and the risk factors for postprocedural complications were evaluated.

RESULTS

All 36 aneurysms in 36 patients were treated successfully. The median clinical follow-up time was 47.0 (IQR: 10.5, 84.5) months. Overall, complications occurred in 10 (27.8%) patients, including 3 (8.3%) deaths. Ischemic events occurred in seven (19.4%) patients, while three (8.3%) patients had shunt-dependent hydrocephalus, of whom one (2.8%) patient had both shunt-dependent hydrocephalus and ischemic events. The cumulative survival rates at 3 and 5 years were 94.1% and 87.8%, respectively. The cumulative 3- and 5-year complication-free survival rates were 75.0% and 70.0%, respectively. Multivariate Cox regression analysis revealed that diabetes mellitus (HR:8.76, 95%CI:2.35-32.69, p=0.001), and Glasgow coma scale score ≤ 12 before the procedure (HR:5.04, 95%CI:1.40-18.12, p=0.013) were associated with overall postprocedural complications. The complete aneurysm occlusion rate was 61.5% at a median angiography follow-up time of 6.0 (IQR: 5.0, 6.0) months.

CONCLUSIONS

Endovascular treatment is a safe and feasible option for treating ruptured BAT aneurysms. The rate of favorable outcomes at the final follow-up was satisfactory. However, postprocedural complications, particularly ischemic events, should be carefully considered.

Early mobilization in patients with aneurysmal subarachnoid haemorrhage may im-prove functional status and reduce cerebral vasospasm rate: a systematic review with meta-analysis

OBJECTIVE

The primary aim of this study was to evaluate the safety and efficacy of early mobilization in patients with aneurysmal subarachnoid haemorrhage.

DESIGN

Systematic review with meta-analysis of randomized controlled studies and observational studies.

PATIENTS

Patients with aneurysmal subarachnoid haemorrhage.

METHODS

PubMed, Embase, CINAHL, Web of Science, Pedro, and the Cochrane Library databases were searched. A systematic review and meta-analysis were performed. Screening and data extraction were performed by 2 independent reviewers.

RESULTS

Sixteen studies involving 1,757 patients were included. Meta-analysis of the data estimated that early mobilization improved mRS score at discharge (mean difference -1.39, 95% CI -2.51 to -0.28, I2 = 86%) and at 3 months (mean difference -1.10, 95% CI -1.54 to -0.66, I2 = 7%). Early mobilization was associated with a reduction in cerebral vasospasm rate, both radiological (OR 0.66, 95% CI 0.45 to 0.96, I2 = 7%) and clinical (OR 0.44, 95% CI 0.27 to 0.72, I2 = 8%); 6% of mobilization sessions involved adverse events, mostly haemodynamic changes.

CONCLUSION

This review found moderate-quality evidence supporting the safety and effectiveness of early mobilization in patients with SAH. Further randomized controlled trials are needed to identify the appropriate mobilization strategy and confirm these results.

Serum sodium concentration predicting mortality in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

To date, inconsistent evidence exists on the role of hypernatremia in patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent surgical clipping. We aimed to investigate the association between serum sodium and mortality in these patients.

METHODS

A cohort study was performed to include adult patients with aSAH who underwent surgical clipping in a university hospital. The primary outcome was follow-up mortality. Propensity score matching (PSM) was used for matching patients' baseline characteristics. Net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to assess and compare the reclassification and discrimination capacity of different models. Trends in serum sodium over time were detected by the ordinary least squares model.

RESULTS

Of 618 aSAH patients with surgical clipping during the study period, normal serum sodium was observed in 467 patients (75.6 %), and admission hypernatremia was noted in 151 patients (24.4 %). After adjustment with multivariate regression analysis, patients with hypernatremia had significantly higher odds for follow-up mortality (aOR: 2.86, 95 % CI: 1.54 to 5.30; P = 0.001). PSM analysis observed similar results (aOR: 2.38, 95 % CI: 1.29 to 4.55; P = 0.009). The incorporation of serum sodium during hospitalization markedly enhanced the IDI (P < 0.001) and NRI (P < 0.001) for the prediction of mortality.

CONCLUSIONS

In conclusion, the findings from this cohort study of aSAH patients with surgical clipping indicated that serum sodium can be an independent predictive factor of all-cause mortality, and inferior sequelae in aSAH patients. These findings endorsed the importance of managing hypernatremia and monitoring serum sodium in patients with aSAH.

Guideline-recommended basic parameter adherence in neurocritical care stroke patients: Observational multicenter individual participant data analysis

INTRODUCTION

Neurocritical care patients with neurovascular disease often face poor long-term outcomes, highlighting the pivotal role of evidence-based interventions. Although International Guidelines emphasize managing basic physiological parameters like temperature, blood glucose, blood pressure, and oxygen levels, physician adherence to these targets remains uncertain. This study aimed to assess adherence to guideline-based treatment targets for basic physiological parameters in neurocritical care.

PATIENTS AND METHODS

This multicenter observational study was conducted across eight tertiary University Hospitals in Germany analyzed 474 patients requiring mechanical ventilation (between January 1st and December 31st, 2021). Adherence was defined as the rate of measurements within therapeutic ranges for systolic blood pressure (situation-adapted), mean blood pressure (MAP, 60-90 mmHg), glucose levels (80-180 mg/dl), body temperature (<37.5°C), partial arterial pressure of oxygen (PaO2) 80-120 mmHg und partial arterial pressure of carbon dioxide (PaCO2) 35-45 mmHg during the initial 96 h of hospitalization in 4 hour-intervals.

RESULTS

Overall, 70.7% of all measurements were within the predetermined therapeutic ranges including SBP (71.3%), temperature (68.3%), MAP (71.4%), PaO2 (65.2%), PaCO2 (75.0%) and blood glucose (80.7%).

DISCUSSION AND CONCLUSION

This multicenter study demonstrates adherence to guideline-based treatment targets, underscoring the high standards maintained by neurological intensive care units. Our study offers valuable insights into adherence to guideline-based treatment targets for neurocritical care patients in Germany. To improve patient care and optimize therapeutic strategies in neurovascular diseases, further research is needed to examine the impact of these adherence parameters on long-term outcomes.

Inhibition of acid-sensing receptor GPR4 attenuates neuronal ferroptosis via RhoA/YAP signaling in a rat model of subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Subarachnoid hemorrhage (SAH) is a devastating stroke, in which acidosis is one of detrimental complications. The extracellular pH reduction can activate G protein-coupled receptor 4 (GPR4) in the brain. Yet, the extent to which proton-activated GPR4 contributes to the early brain injury (EBI) post-SAH remains largely unexplored. Ferroptosis, iron-dependent programmed cell death, has recently been shown to contribute to EBI. We aimed to investigate the effects of GPR4 inhibition on neurological deficits and neuronal ferroptosis after SAH in rats.

METHODS

A total 253 Sprague Dawley (SD) male rats (weighing 275-330g) were utilized in this study. SAH was induced by endovascular perforation. NE-52-QQ57 (NE), a selective antagonist of GPR4 was administered intraperitoneally 1-h post-SAH. To explore the mechanisms, RhoA activator U-46619 and YAP activator PY-60 were delivered intracerebroventricularly. Short- and long-term neurobehavior, SAH grading, Western blot assay, ELISA assay, immunofluorescence staining, and transmission electron microscopy was performed post-SAH.

RESULTS

Following SAH, there was an upregulation of GPR4 expression in neurons. GPR4 inhibition by NE improved both short-term and long-term neurological outcomes post-SAH. NE also reduced neuronal ferroptosis, as evidenced by decreased lipid peroxidation products 4HNE and MDA levels in brain tissues, and reduced mitochondrial shrinkage, increased mitochondria crista and decreased membrane density. The application of either U-46619 or PY-60 partially offset the neuroprotective effects of NE on neuronal ferroptosis in SAH rats.

CONCLUSIONS

This study demonstrated that acid-sensing receptor GPR4 contributed to neuronal ferroptosis after SAH via RhoA/YAP pathway, and NE may be a potential therapeutic strategy to attenuate GPR4 mediated neuronal ferroptosis and EBI after SAH.

Temporal trends and practice variation in early repair of the ruptured aneurysm among patients with aneurysmal subarachnoid hemorrhage in the United States, 2012-2019

BACKGROUND

Early repair of the ruptured cerebral aneurysm (RRCA), preferably within 24 h of onset, is endorsed by clinical guideline as the preferred management strategy for patients with aneurysmal subarachnoid hemorrhage (aSAH). However, a comprehensive picture of this guideline-recommended usage in contemporary clinical practice is not available.

AIMS

This study aimed to characterize trends over time and practice variation in the implementation of an early RRCA strategy among patients with aSAH in a large, national representative data.

METHODS

Using data from the 2012-2019 National Inpatient Sample, we measured trends in the proportion of early RRCA, defined as within day 1 of admission, overall, and by demographic and geographical subgroups. In addition, we created multilevel regression models to quantify hospital-level variation in the early RRCA rates.

RESULTS

We identified 82,615 aSAH hospitalizations (mean age = 56.1 years; 68.9% women) undergoing RRCA and, among these, 84.0% (95% confidence interval (CI) = 83.4-84.7%) receiving early RRCA. The proportion of early RRCA increased steadily from 82.5% in 2012 to 85.8% in 2019 (p for trend <0.001). The proportion of patients receiving early RRCA across geographic regions ranged from 78.7% to 87.9%, with a median (interquartile range (IQR)) of 84.2% (83.0-86.1%). In contrast, the delivery of early RRCA varied widely among hospitals, with a median (IQR) rate of 86.1% (75.0-100.0%) and a range from 0% to 100.0%. The median odds ratio for the early use of RRCA treatment was 1.24 (95% CI = 1.21-1.27) in 2019, indicating 24% increased odds of implementing early RRCA if moving from a lower-use to a higher-use hospital.

CONCLUSIONS

Most patients in the United States with aSAH received early RRCA treatment and exhibited an upward trend over the recent 8-year period. However, substantial variation in access to early RRCA was observed across population subgroups, particularly at the hospital level. Future efforts are necessary to identify further sources of this variation and to develop initiatives that could represent an opportunity to optimize guideline-based quality of care in aSAH management.

DATA ACCESS STATEMENT

The data are available from the corresponding author upon reasonable request following completion of onboarding and verification procedures as specified by the HCUP.

The Impact of Systolic Blood Pressure Reduction on Aneurysm Re-Bleeding in Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND

Preventing early aneurysm rebleeding is crucial in the management of aneurysmal subarachnoid hemorrhage (SAH). Lowering systolic blood pressure (SBP) has been proposed as a potential strategy, but the evidence remains inconclusive. This systematic review and meta-analysis aimed to determine if a specific SBP target could reduce the risk of aneurysm rebleeding prior to treatment.

METHODS

Electronic databases were systematically searched for studies comparing SBP between SAH patients with and without aneurysm rebleeding before surgical treatment. Data on SBP values, patient characteristics, and rebleeding events were extracted. Meta-analyses were performed to pool mean SBP differences and odds ratios (ORs) for rebleeding at different SBP cut-offs.

RESULTS

Ten studies were included in the systematic review. Pooled data from the included studies showed that the mean SBP was higher in the rebleeding group (mean difference 5.89, 95% CI 1.94 to 9.85). SBP ≤160 mmHg was associated with lower rebleeding risk (OR 0.30, 95% CI 0.14 to 0.65). However, substantial heterogeneity and limitations in study designs and definitions were noted.

CONCLUSIONS

This meta-analysis suggests that SAH patients with rebleeding may present with higher SBP. However, the findings should be interpreted cautiously due to study limitations. Future prospective studies with standardized definitions and comprehensive data collection are needed to elucidate the complex relationship between blood pressure dynamics and rebleeding risk in SAH.

Which Intravenous Isotonic Fluid Offers Better Outcomes for Patients with a Brain Injury?

Administering intravenous fluids is a common therapy for critically ill patients. Isotonic crystalloid solutions, such as saline or balanced solutions, are frequently used for intravenous fluid therapy. The choice between saline or a balanced crystalloid has been a significant question in critical care medicine. Recent large randomized controlled trials (RCTs) have investigated whether balanced crystalloids yield better outcomes in general or specific critical care populations, and many of them have confirmed this hypothesis. Although the broad eligibility criteria of these RCTs suggest applicability to neurocritical care patients, it is important to discuss whether using balanced crystalloids, as opposed to saline, would benefit patients who primarily have neurological disorders or diseases. This review considers the relevance of this question, weighs the pros and cons of the two fluid types, examines available data, and anticipates results from ongoing RCTs to guide clinicians in selecting the optimal fluid for patients with brain injury.

Subarachnoid haemorrhage in the emergency department (SHED): a prospective, observational, multicentre cohort study

BACKGROUND

People presenting to the ED with acute severe headache often undergo investigation to exclude subarachnoid haemorrhage (SAH). International guidelines propose that brain imaging within 6 hours of headache onset can exclude SAH, in isolation. The safety of this approach is debated. We sought to externally validate this strategy and evaluate the test characteristics of CT-brain beyond 6 hours.

METHODS

A prospective, multicentre, observational cohort study of consecutive adult patients with non-traumatic acute headache presenting to the ED within a UK National Health Service setting. Investigation, diagnosis and management of SAH were all performed within routine practice. All participants were followed up for 28 days using medical records and direct contact as necessary. Uncertain diagnoses were independently adjudicated.

RESULTS

Between March 2020 and February 2023, 3663 eligible patients were enrolled from 88 EDs (mean age 45.8 (SD 16.6), 64.1% female). 3268 patients (89.2%) underwent CT-brain imaging. There were 237 cases of confirmed SAH, a prevalence of 6.5%. CT within 6 hours of headache onset (n=772) had a sensitivity of 97% (95% CI 92.5% to 99.2%) for the diagnosis of SAH and a negative predictive value of 99.6% (95% CI 98.9% to 99.9%). The post-test probability after a negative CT within 6 hours was 0.5% (95% CI 0.2% to 1.3%). The negative likelihood ratio was 0.03 (95% CI 0.01 to 0.08). CT within 24 hours of headache onset (n=2008) had a sensitivity of 94.6% (95% CI 91.0% to 97.0%). Post-test probability for SAH was consistently less than 1%. For aneurysmal SAH, post-test probability was 0.1% (95% CI 0.0% to 0.4%) if the CT was performed within 24 hours of headache onset.

CONCLUSION

Our data suggest a very low likelihood of SAH after a negative CT-brain scan performed early after headache onset. These results can inform shared decision-making on the risks and benefits of further investigation to exclude SAH in ED patients with acute headache.

Smartphone pupillometry for detection of cerebral vasospasm after aneurysmal subarachnoid hemorrhage

OBJECTIVES

Vasospasm is a complication of aneurysmal subarachnoid hemorrhage (aSAH) that can change the trajectory of recovery and is associated with morbidity and mortality. Earlier detection of vasospasm could improve patient outcomes. Our objective is to evaluate the accuracy of smartphone-based quantitative pupillometry in the detection of radiographic vasospasm and delayed cerebral ischemia (DCI) after aSAH.

MATERIALS AND METHODS

We prospectively collected pupillary light reflex (PLR) parameters from patients with aSAH admitted to a neurocritical care unit at a single hospital twice daily using quantitative smartphone pupillometry recordings. PLR parameters included: Maximum pupil diameter, minimum pupil diameter, percent change in pupil diameter, latency in beginning of pupil constriction to light, mean constriction velocity, maximum constriction velocity, and mean dilation velocity. Two-tailed t-tests for independent samples were performed to determine changes in average concurrent PLR parameter values between the following comparisons: (1) patients with and without radiographic vasospasm (defined by angiography with the need for endovascular intervention) and (2) patients with and without DCI.

RESULTS

49 subjects with aSAH underwent 323 total PLR recordings. For PLR recordings taken with (n=35) and without (n=241) radiographic vasospasm, significant differences were observed in MIN (35.0 ± 7.5 pixels with vasospasm versus 31.6 ± 6.2 pixels without; p=0.002). For PLR recordings taken with (n=43) and without (n=241) DCI, significant differences were observed in MAX (48.9 ± 14.3 pixels with DCI versus 42.5 ± 9.2 pixels without; p<0.001).

CONCLUSIONS

Quantitative smartphone pupillometry has the potential to be used to detect radiographic vasospasm and DCI after aSAH.

Association Between Early Mobilization and Functional Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Propensity Score-Matched Study

BACKGROUND

Early mobilization has been shown to promote functional recovery and prevent complications in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the efficacy of early mobilization in patients with aSAH remains unclear. This study aimed to investigate the association between early mobilization and functional outcomes in patients with aSAH.

METHODS

This multicenter retrospective study was conducted in Japan and included patients with aSAH who received physical therapy with or without occupational therapy from April 2014 to March 2019. The primary outcome was the modified Rankin Scale (mRS) score, with a favorable functional outcome defined as an mRS score of 0-2 and an unfavorable outcome with an mRS score of 3-5. Patients initiating walking training within 14 days of aSAH onset were classified into the early mobilization group, whereas those initiating training after 14 days were classified into the delayed mobilization group. Propensity score matching analysis was performed to assess the association between early mobilization and favorable outcomes.

RESULTS

A total of 718 patients were screened, and 450 eligible patients were identified. Before matching, 229 patients (50.9%) were in the early mobilization group and 221 (49.1%) were in the delayed mobilization group. After matching, each group consisted of 122 patients, and the early mobilization group exhibited a higher proportion of favorable outcomes than did the delayed mobilization group (81.1% vs. 52.5%, risk difference 28.7%, 95% confidence interval 17.4-39.9, p < 0.001).

CONCLUSIONS

This multicenter retrospective study suggests that initiating walking training within 14 days of aSAH onset is associated with favorable outcomes.

Longitudinal changes in the US emergency department use of advanced neuroimaging in the mechanical thrombectomy era

PURPOSE

To describe ED neuroimaging trends across the time-period spanning the early adoption of endovascular therapy for acute stroke (2013-2018).

MATERIALS AND METHODS

We performed a retrospective, cross-sectional study of ED visits using the 2013-2018 National Emergency Department Sample, a 20% sample of ED encounters in the United States. Neuroimaging use was determined by Common Procedural Terminology (CPT) code for non-contrast head CT (NCCT), CT angiography head (CTA), CT perfusion (CTP), and MRI brain (MRI) in non-admitted ED patients. Data was analyzed according to sampling weights and imaging rates were calculated per 100,000 ED visits. Multivariate logistic regression analysis was performed to identify hospital-level factors associated with imaging utilization.

RESULTS

Study population comprised 571,935,906 weighted adult ED encounters. Image utilization increased between 2013 and 2018 for all modalities studied, although more pronounced in CTA (80.24/100,000 ED visits to 448.26/100,000 ED visits (p < 0.001)) and CTP (1.75/100,000 ED visits to 28.04/100,000 ED visits p < 0.001)). Regression analysis revealed that teaching hospitals were associated with higher odds of high CTA utilization (OR 1.88 for 2018, p < 0.05), while low-volume EDs and public hospitals showed the reverse (OR 0.39 in 2018, p < 0.05).

CONCLUSIONS

We identified substantial increases in overall neuroimaging use in a national sample of non-admitted emergency department encounters between 2013 and 2018 with variability in utilization according to both patient and hospital properties. Further investigation into the appropriateness of this imaging is required to ensure that access to acute stroke treatment is balanced against the timing and cost of over-imaging.

Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke

Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.

Analysis of Cerebral Spinal Fluid Drainage and Intracranial Pressure Peaks in Patients with Subarachnoid Hemorrhage

BACKGROUND

After aneurysmal subarachnoid hemorrhage (aSAH), elevated intracranial pressure (ICP) due to disrupted cerebrospinal fluid (CSF) dynamics is a critical concern. An external ventricular drainage (EVD) is commonly employed for management; however, optimal strategies remain debated. The randomized controlled Earlydrain trial showed that an additional prophylactic lumbar drainage (LD) after aneurysm treatment improves neurological outcome. We performed a post hoc investigation on the impact of drainage volumes and critical ICP values on patient outcomes after aSAH.

METHODS

Using raw patient data from Earlydrain, we analyzed CSF drainage amounts and ICP measurements in the first 8 days after aSAH. Outcomes were the occurrence of secondary infarctions and the score on the modified Rankin scale after 6 months, dichotomized in values of 0-2 as favorable and 3-6 as unfavorable. Repeated measurements were considered with generalized estimation equations.

RESULTS

Earlydrain recruited 287 patients, of whom 221 received an EVD and 140 received an LD. Higher EVD volumes showed a trend to more secondary infarctions (p = 0.09), whereas higher LD volumes were associated with less secondary infarctions (p = 0.009). The mean total CSF drainage was 1052 ± 659 mL and did not differ concerning infarction and neurological outcome. Maximum ICP values were higher in patients with poor outcomes but not related to drainage volumes via EVD. After adjustment for aSAH severity and total CSF drainage, higher LD volume was linked to favorable outcome (per 100 mL: odds ratio 0.61 (95% confidence interval 0.39-0.95), p = 0.03), whereas higher EVD amounts were associated with unfavorable outcome (per 100 mL: odds ratio 1.63 (95% confidence interval 1.05-2.54), p = 0.03).

CONCLUSIONS

Findings indicate that effects of CSF drainage via EVD and LD differ. Higher amounts and higher proportions of LD volumes were associated with better outcomes, suggesting a potential quantity-dependent protective effect. Optimizing LD volume and mitigating ICP spikes may be a strategy to improve patient outcomes after aSAH.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01258257.

Localized Nicardipine Release Implants for Prevention of Vasospasm After Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial

Importance

Cerebral vasospasm largely contributes to a devastating outcome after aneurysmal subarachnoid hemorrhage (aSAH), with limited therapeutic options.

Objective

To investigate the safety and efficacy of localized nicardipine release implants positioned around the basal cerebral vasculature at risk for developing proximal vasospasm after aSAH.

Design, Setting, and Participants

This single-masked randomized clinical trial with a 52-week follow-up was performed between April 5, 2020, and January 23, 2023, at 6 academic neurovascular centers in Germany and Austria. Consecutive patients with World Federation of Neurological Surgeons grade 3 or 4 aSAH due to a ruptured anterior circulation aneurysm requiring microsurgical aneurysm repair participated.

Intervention

During aneurysm repair, patients were randomized 1:1 to intraoperatively receive 10 implants at 4 mg of nicardipine each plus standard of care (implant group) or aneurysm repair alone plus standard of care (control group).

Main Outcome and Measures

The primary end point was the incidence of moderate to severe cerebral angiographic vasospasm (aVS) between days 7 and 9 after aneurysm rupture as determined by digital subtraction angiography.

Results

Of 41 patients, 20 were randomized to the control group (mean [SD] age, 54.9 [9.1] years; 17 female [85%]) and 21 to the implant group (mean [SD] age, 53.6 [11.9] years; 14 female [67%]). A total of 39 patients were included in the primary efficacy analysis. In the control group, 11 of 19 patients (58%) developed moderate or severe aVS compared with 4 of 20 patients (20%) in the implant group (P = .02). This outcome was paralleled by a lower clinical need for vasospasm rescue therapy in the implant group (2 of 20 patients [10%]) compared with the control group (11 of 19 patients [58%]; P = .002). Between days 13 and 15 after aneurysm rupture, new cerebral infarcts were noted in 6 of 19 patients (32%) in the control group and in 2 of 20 patients (10%) in the implant group (P = .13). At 52 weeks, favorable outcomes were noted in 12 of 18 patients (67%) in the control group and 16 of 19 patients (84%) in the implant group (P = .27). The adverse event rate did not differ between groups.

Conclusions and Relevance

These findings show that placing nicardipine release implants during microsurgical aneurysm repair can provide safe and effective prevention of moderate to severe aVS after aSAH. A phase 3 clinical trial to investigate the effect of nicardipine implants on clinical outcome may be warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT04269408.

An Improvised External Ventricular Drain Fixation Technique to Avoid Pullout-Related Complications in a Low-Resource Setting: A Descriptive Cross-Sectional Study in a Single Center of Nepal

BACKGROUND AND OBJECTIVES

An external ventricular drain (EVD) placement is a commonly performed life-saving procedure. Its accidental pullout can occur in complex environments, patient care, and positioning, which leads to significant morbidity. The method of EVD fixation and pullout rates is sparsely described in the literature, and there exists a wide variation among the techniques practiced for fixation. However, some techniques require additional tools, which are expensive and unavailable in low-resource settings. We describe an improvised method of securely fixing the EVD to the scalp applicable in low-resources and describe the EVD pullout rate with the use of this technique.

METHODS

A retrospective review of pullout-related complications in 107 consecutive patients was performed. The EVD was fixed to the scalp using an improvised technique to loop the catheter around a soft flange and secure it with sutures.

RESULTS

Pullout occurred in 1 patient (0.93%), who was in an alcohol withdrawal state and deliberately pulled out the catheter. There were zero nondeliberate pullouts.

CONCLUSION

EVD fixation by coiling the catheter around a soft flange has a low pullout rate. Because it is secure and requires only a flange, it is suitable for low-resource settings.

Endovascular surgical neuro-oncology: advancing a new subspecialty

Endovascular surgical neuro-oncology is a relatively new subspecialty which uses endovascular neuro-interventional techniques for the management of nervous system tumors and tumor-related vascular conditions. Although there are several endovascular procedures that are widely available as standard-of-care diagnostic and treatment adjuncts, there has been a renewed interest to explore endovascular approaches as a means for selective intra-arterial delivery of therapeutic agents to nervous system tumors, including methods for opening the blood brain and blood tumor barriers. In this review, we discuss the historical development of various forms of endovascular intra-arterial treatment for tumors over the past 40 years, summarize endovascular approaches that are currently being employed, and highlight current clinical trials.

Causal relationships between gut microbiota and Aneurysmal Subarachnoid Hemorrhage: A Bidirectional Mendelian Randomization Study

BACKGROUND AND PURPOSE

Aneurysmal Subarachnoid Hemorrhage (aSAH) poses a significant health burden globally, necessitating a deeper understanding of its etiology and potential preventive strategies. Recent research has suggested a possible link between gut microbiota composition and the risk of vascularity, prompting investigation into this association using Mendelian Randomization (MR) analysis. Here, we aimed to elucidate the causal relationship between gut microbiota composition and aSAH risk utilizing MR analysis.

METHODS

We employed four distinct MR methodologies, including inverse variance weighted (IVW), MR-Egger, weighted median, and weighted mode, to assess the causal nexus between gut microbiota composition and aSAH risk. Genetic instrumental variables (IVs) associated with gut microbiome composition were selected from a comprehensive multiethnic genome-wide association study (GWAS) involving 18,473 individuals across diverse geographic regions. Sensitivity analyses were conducted to detect potential heterogeneity and pleiotropy.

RESULTS

Our Mendelian Randomization (MR) analyses unveiled a substantial and statistically significant causal relationship between gut microbiota composition and the risk of Aneurysmal Subarachnoid Hemorrhage (aSAH). Employing the Inverse Variance Weighted (IVW) method, we observed negative associations between aSAH and specific taxonomic levels of gut microbiota. Specifically, the IVW approach identified significant associations with one order, Victivallales (PIVW=0.047, OR: 0.78, 95 % CI: 0.62-0.99), one family, Porphyromonadaceae (PIVW=0.03, OR: 0.64, 95 % CI: 0.43-0.95), one class, Lentisphaeria (PIVW=0.047, OR: 0.78, 95 % CI: 0.62-0.99), and three genera: Bilophila (PIVW=0.02, OR: 0.68, 95 % CI: 0.50-0.93), Fusicatenibacter (PIVW=0.04, OR: 0.69, 95 % CI: 0.49-0.98), and Ruminococcus1 (PIVW=0.01, OR: 0.51, 95 % CI: 0.32-0.84). These findings were consistent across various MR methodologies, underscoring the robustness of our results. Sensitivity analyses further validated the stability of our findings, with no evidence of heterogeneity or pleiotropy detected.

CONCLUSION

Our study provides compelling evidence supporting a causal relationship between gut microbiota composition and the risk of aSAH. These findings underscore the potential therapeutic implications of modulating gut microbiota to prevent and manage aSAH. Further research is warranted to explore the underlying mechanisms and develop targeted interventions aimed at mitigating aSAH risk through gut microbiota modulation.

Comparison of Risk Factors for Early Seizures Between Angiogram-Negative and Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Early-onset seizures are common in aneurysmal subarachnoid hemorrhage (aSAH), with risk factors that have been explored. However, early-onset seizures in patients with angiogram-negative nonperimesencephalic SAH (an-SAH) are less understood. We sought to compare the incidence and risk factors of early-onset seizures between these groups.

METHODS

We conducted a retrospective study of a cohort of consecutive patients admitted to an academic center between July 2016 and July 2023. Patients were categorized into aSAH or an-SAH based on imaging findings. Clinical data and electroencephalogram findings were retrieved and analyzed. Multivariable logistic regression analysis was used to determine risk factors for clinical or electrographic seizures, as well as other epileptic features.

RESULTS

We included 473 patients (63% female) in the final analysis, of whom 79 had an-SAH and 394 had aSAH. Patients with an-SAH were older (mean age 61.9 years [standard deviation 15.9] vs. 56.7 [standard deviation 13.4]; p = 0.02). The rate of clinical or electrographic seizures was similar between the two groups (13% in aSAH vs. 11% in an-SAH; p = 0.62). Highly epileptic features (electrographic seizures, ictal-interictal continuum, and periodic epileptic discharges) occurred more frequently in the aSAH group compared with the an-SAH group, although this difference was not significant (15% vs. 8%; p = 0.09). Risk factors for seizures in aSAH were Hunt and Hess grade (odds ratio [OR] 1.25 per grade increase, 95% confidence interval [CI] 1.05-1.49; p = 0.011), modified Fisher score (OR 1.64 per point increase, 95% CI 1.25-2.15; p < 0.001), cerebral infarct (OR 3.64, 95% CI 2.13-6.23; p < 0.001), and intracerebral hemorrhage (OR 10, 95% CI 1.35-76.9; p = 0.017). However, none of these factors were associated with seizures in an-SAH.

CONCLUSIONS

Early-onset seizures occur at similar rates in patients with an-SAH and aSAH. However, seizure risk factors appear to differ between these groups. Larger prospective studies are needed to identify predictors of seizures in patients with an-SAH.

Increased brain volume in the early phase of aneurysmal subarachnoid hemorrhage leads to delayed cerebral ischemia

Objective

To investigate the correlation between the swelling rate of brain volume within the first 48 h after aneurysmal subarachnoid hemorrhage and the subsequent development of delayed cerebral ischemia.

Methods

A retrospective analysis was conducted on patients with spontaneous aneurysmal subarachnoid hemorrhage admitted to the Neurosurgery Intensive Care Unit of the First Affiliated Hospital of Chongqing Medical University between January 2020 and January 2023. The clinical data, treatment outcomes, and imaging data were analyzed. Brain volume was evaluated using 3D-Slicer software at two time points post-hemorrhage: within the first 24 h and between 24 and 48 h. The swelling rate of brain volume was defined as the ratio of the absolute difference between two measurements to the smaller of values. Patients were categorized into two groups based on established diagnostic criteria of delayed cerebral ischemia. Univariate and multivariate logistic regression analyses were performed to identify factors influencing delayed cerebral ischemia.

Results

A total of 140 patients were enrolled in this study. 46 patients experienced delayed cerebral ischemia after bleeding. The swelling rate of brain volume was larger in the DCI group (10.66 ± 8.45) compared to the non-DCI group (3.59 ± 2.62), which showed a statistically significant difference. Additionally, advanced age, smoking history, history of hypertension, loss of consciousness, poor Hunt-Hess grade, high mFisher score, brain volume within 24 h, and IVH were also statistically different between the two groups. Multivariate logistic regression analysis revealed that the swelling rate of brain volume was an independent risk factor for DCI with adjusting the advanced age, smoking history, history of hypertension, poor Hunt-Hess grade, high mFisher score, brain volume within 24 h, and IVH.

Conclusion

Brain volume significantly increased in patients with aneurysmal subarachnoid hemorrhage during the early phase (within 48 h post-onset). The larger swelling rate of brain volume is an independent risk factor for the development of delayed cerebral ischemia, and it may hold significant predictive value for the incidence of delayed cerebral ischemia.

Bacterial Meningitis Following Aneurysmal Subarachnoid Hemorrhage and Its Association with Cerebral Vasospasm

Aneurysmal subarachnoid hemorrhage (aSAH) is a critical condition with high in-hospital mortality rates. Delayed cerebral ischemia (DCI), a secondary complication associated with aSAH, can also contribute to morbidity and mortality. Although draining the hematoma from the subarachnoid space has been considered effective in preventing DCI, the placement of a drainage system could increase the risk of bacterial meningitis and ventriculitis. This study aimed to examine the association between meningitis following aSAH and the occurrence of DCI, focusing on the role of cerebral vasospasm. Patients who underwent endovascular coiling or surgical clipping for aSAH from April 2001 to March 2022 were included in this study, while those who did not undergo postoperative drainage were excluded. The patient's clinical characteristics, treatment modalities, and outcomes were then analyzed, after which logistic regression was used to assess the odds ratios (OR) for DCI. A total of 810 patients with aSAH were included in this study. Meningitis following aSAH was identified as an independent factor associated with DCI (odds ratio 5.0 [95% confidence intervals (CI) 2.3-11]). Other significant factors were female sex (odds ratio 1.5 [95% CI 0.89-2.5]) and surgical clipping (odds ratio 2.1 [95% CI 1.3-3.4]). This study demonstrated a significant association between meningitis following aSAH and the development of DCI, suggesting that the inflammatory environment associated with meningitis may contribute to cerebral vasospasm. Early recognition and treatment of meningitis in patients with aSAH could reduce the risk of DCI and improve patient outcomes.

Impact of Clevidipine Versus Nicardipine on Time in Range when Lowering Blood Pressure

Background: Two intravenous medications commonly used as first-line therapy for rapid blood pressure control are nicardipine and clevidipine, both of which are available as titratable infusions. Despite pharmacokinetic differences, no data clearly support a preferred agent. Objective: To evaluate efficacy and safety outcomes associated with current use of these medications across a variety of indications in a hospital system. Methods: This study was a multi-center, retrospective chart review conducted within a hospital system from June 1, 2020 to June 30, 2021. Records of patients were matched in a one-to-one fashion based on indication for blood pressure control and similar pre-intervention blood pressure. The primary outcome was time within target blood pressure range. Results: A total of 569 patients were screened, resulting in 100 matched pairs. The percent of time in blood pressure range was similar between nicardipine and clevidipine when stratified by location of care (51.5% vs 51.7%, P = 0.970 for ED; 68.1% vs 68.8%, P = 0.913 for ICU). Overall, the median (IQR) time to target blood pressure range was significantly faster with clevidipine than nicardipine [20 (7-43) min. vs 34 (14.5-57) min., resp.; P = 0.013). There were numerically higher rates of hypotension with nicardipine than clevidipine, but this finding was not significant (17% vs 10%; P = 0.093). Conclusions: This study shows a statistically significant difference in time to target blood pressure range with clevidipine compared to nicardipine. Although there was no difference in the percentage of time in blood pressure range, nicardipine was associated with a non-significant increase in the incidence of hypotension.

Comparison of LVIS and Enterprise stent-assisted coiling embolization for ruptured intracranial aneurysms: a propensity score-matched cohort study

The role of a low-profile visualized intraluminal support stent (LVIS) and Enterprise in the treatment of unruptured intracranial aneurysms is well established. Although previous studies have investigated one single type of stent for the treatment of ruptured intracranial aneurysms (RIA), the safety and efficacy between the two types of stents has not been fully explored. Herein we conducted a study to compare the outcomes of the two stents for treatment of RIA. This is a prospective registry database of aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to a single institution between 2018 and 2021. We collected patient baseline information, secondary complications, follow-up angiographic data, long-term prognostic outcomes, and conducted propensity score matching (PSM) analysis with 1:1 ratio and a multivariable logistic regression to compare the outcomes of the two types of stents. A total of 231 patients with RIAs were included in this study, with 108 treated using the LVIS device and 123 treated using the Enterprise device. Before PSM analysis, only the incidence of poor prognosis after 12 months was higher in the Enterprise group comparing to the LVIS group (20% vs. 10%, P = 0.049). After PSM analysis, there was a higher occurrence of delayed cerebral ischemia (DCI) in the Enterprise group compared to the LVIS group (odds ratio [OR] 3.95, 95% confidence interval [CI] [1.20-13.01], P = 0.024). However, no significant difference in prognosis was observed after PSM adjustment. Furthermore, subgroup analysis revealed that patients with female (P = 0.019), hypertension (P = 0.048), and anterior circulation aneurysms (P = 0.019) receiving the Enterprise device had a higher risk of DCI. The overall efficacy of LVIS and Enterprise in the treatment of RIA is comparable, while the incidence of DCI in the LVIS group is lower than that in the Enterprise group after PSM analysis. Registration number: NCT05738083 ( https://clinicaltrials.gov/ ).

An overview of decision-making in cerebrovascular treatment strategies: Part II - Ruptured aneurysms

Introduction

Decision-making for the treatment of ruptured aneurysms is an intricate process, which involves several factors. There has been a rapid advancement in endovascular, but also in the surgical treating field of ruptured intracranial aneurysms, with a growing body of evidence for either treatment technique.

Research question

As there is a wide variety of treatment possibilities, it can be hard to understand the intricacies which lie behind the decision-making process for a given aneurysm.

Materials and methods

An overview of the most relevant literature in decision-making on ruptured intracranial aneurysms is given.

Results

Different decision-altering factors were identified, which can be divided into information from the general evidence, to influential factors such as the patient's age, initial presenting status, and aneurysmal factors such as size, morphology and aneurysmal location.

Discussion and conclusion

This review provides an evidence-based overview of the most pertinent literature on these different aspects of decision-making in ruptured aneurysm cases and provides some recommendations after each of these segments. As always, all different aspects of the patient and aneurysmal factors should be taken into consideration before coming to a conclusion, as to obtain the best possible result for an individual patient.

Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization

Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.

Prevalence of small vessel disease and incidental DWI-positive lesions in patients with aneurysmal subarachnoid hemorrhage versus intracerebral hemorrhage

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (aSAH) and intracerebral hemorrhage (ICH) are main forms of hemorrhagic stroke. Data regarding cerebral small vessel disease (SVD) burden and incidental small lesions on diffusion-weighted imaging (DWI) following aSAH are sparse.

PATIENTS AND METHODS

We retrospectively analyzed a prospective cohort of aSAH and ICH patients with brain MRI within 30 days after onset from March 2015 to January 2023. White matter hyperintensity (WMH), lacune, perivascular space, cerebral microbleed (CMB), total SVD score, and incidental DWI lesions were assessed and compared between aSAH and ICH. Clinical and radiological characteristics associated with small DWI lesions in aSAH were investigated.

RESULTS

We included 180 patients with aSAH (median age [IQR] 53 [47-61] years) and 299 with ICH (63 [53-73] years). DWI lesions were more common in aSAH than ICH (47.8% vs 14.4%, p < 0.001). Higher total SVD score was associated with ICH versus aSAH irrespective of hematoma location, whereas DWI lesions and strictly lobar CMBs were correlated with aSAH. Multivariable analysis showed that shorter time from onset to MRI, anterior circulation aneurysm rupture, CMB ⩾ 5, and total SVD score were associated with DWI lesions in aSAH.

DISCUSSION AND CONCLUSION

Incidental DWI lesions and strictly lobar CMBs were more frequent in aSAH versus ICH whereas ICH had higher SVD burden. Incidental DWI lesions in aSAH were associated with multiple clinical and imaging factors. Longitudinal studies to investigate the dynamic change and prognostic value of the covert hemorrhagic and ischemic lesions in aSAH seem justified.

Comparative diagnostic efficacy of cranial CT, CTA, and DSA in subarachnoid hemorrhage management: A systematic review and meta-analysis

INTRODUCTION

Subarachnoid hemorrhage (SAH) is a critical medical condition associated with high morbidity and mortality rates. Timely and accurate diagnosis is crucial for optimal patient outcomes. Cranial computed tomography (CT), computed tomography angiography (CTA), and digital subtraction angiography (DSA) are commonly used imaging modalities for diagnosing SAH, but their comparative diagnostic efficacy remains debated.

METHODS

A systematic review and meta-analysis was conducted to evaluate the diagnostic performance of cranial CT, CTA, and DSA in identifying SAH. PubMed, Google scholar, Cochrane Library databases were searched for relevant studies published up to January 2024. Pooled sensitivity, specificity, and the summary receiver operating characteristic (SROC) curve were calculated using Review Manager 5.4.

RESULTS

A total of 31 studies involving 10,287 patients were included in the analysis. The pooled sensitivity of cranial CT for detecting SAH was 94.7 % (95 % Confidence Interval, CI) with a specificity of 98.3 % (95 % CI). CTA demonstrated a pooled sensitivity of 94.1 % (95 % CI) and specificity of 93.4 % (95 % CI). DSA showed a pooled sensitivity of 87.7 % (95 % CI) and specificity of 95.8 % (95 % CI). The SROC curve demonstrated discriminatory ability for all modalities.

CONCLUSION

Cranial CT, CTA, and DSA are valuable imaging modalities for diagnosing SAH, with high sensitivity and specificity. Cranial CT serves as an initial screening tool, while CTA offers superior sensitivity in detecting aneurysmal SAH. DSA remains essential in specific clinical scenarios. Further prospective studies are needed to validate these findings and refine diagnostic guidelines for SAH.

Advancing diagnostic precision of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: The potential for a vasospasm index score on perfusion imaging to detect vasospasm

BACKGROUND

The occurrence of delayed cerebral ischemia and vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) results in high morbidity and mortality, but the diagnosis remains challenging. This study aimed to identify neuroimaging perfusion parameters indicative of delayed cerebral ischemia in patients with suspected vasospasm.

METHODS

This is a case-control study. Cases were adult aSAH patients who underwent magnetic resonance perfusion or computed tomography perfusion (CTP) imaging ≤ 24 h before digital subtraction angiography performed for vasospasm diagnosis and treatment. Controls were patients without aSAH who underwent CTP. Quantitative perfusion parameters at different thresholds, including Tmax 4-6-8-10 s delay, cerebral blood flow and cerebral blood volume were measured and compared between cases and controls. The Vasospasm Index Score was calculated as the ratio of brain volume with time-to-max (Tmax) delay > 6 s over volume with Tmax > 4 s.

RESULTS

54 patients with aSAH and 119 controls without aSAH were included. Perfusion parameters with the strongest prediction of vasospasm on cerebral angiography were the combination of the Vasospasm Index Score (Tmax6/Tmax4) + CBV ≤ 48 % (area under the curve value of 0.85 [95 % CI 0.78-0.91]) with a sensitivity of 63 % and specificity of 95 %.

CONCLUSION

The Vasospasm Index Score in combination with CBV ≤ 48 % on cerebral perfusion imaging reliably identified vasospasm as the cause of DCI on perfusion imaging.

Acute Neurological Emergency With Varied Challenges: An Unusual Occurrence and Multimodal Team Approach

Subarachnoid hemorrhage (SAH) is a devastating condition associated with high mortality and morbidity. Vascular malformations are the most common cause of non-traumatic SAH in patients less than 40 years old. We present a case of a 37-year-old male who presented on the second day of ictus with left-sided hemiparesis and a low Glasgow Coma Scale score (E1VTM5). Non-contrast computed tomography (NCCT) scan of the head was suggestive of right basi-frontal hematoma, SAH, and hydrocephalus (HCP). Given SAH with HCP, the neurosurgical team initially placed a left frontal Ommaya. Cerebral digital subtraction angiography suggested an arteriovenous malformation (AVM) and two anterior cerebral artery aneurysms. Endovascular coiling of the ruptured A2-A3 junction aneurysm was done initially, followed by decompressive craniectomy and evacuation of hematoma and clipping of the still leaky A2-A3 junction aneurysm, also on the same day. The patient recovered in the intensive care unit and was discharged home in good health on the 18th postoperative day. Our case report presents the unique challenge of neuroprotection and maintaining intra-cerebral dynamics in a patient with cerebral aneurysms, AVM, SAH, and hematoma between coagulation (to prevent intra-cerebral hemorrhage) versus anti-coagulation (to prevent emboli during coiling), hypertensive therapy (to prevent cerebral vasospasm) versus relative normotension (to prevent rebleed), and early intervention (surgery and coiling) versus staged procedure. Our multimodal team approach was highly effective in successfully managing the patient and thus highlights its role in managing such critically ill patients.

Patients with aneurysmal subarachnoid haemorrhage treated in Swedish intensive care: A registry study

BACKGROUND

Aneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening disease with high mortality and morbidity. Patients with aSAH in Sweden are cared for at one of six neuro intensive care units (NICU) or at a general intensive care unit (ICU).This study aimed to describe the incidence, length of stay, time in ventilator and mortality for these patients.

METHODS

This is a retrospective, descriptive study of patients with aSAH, registered in the Swedish Intensive care Registry between 2017 and 2019. The cohort was divided in sub-cohorts (NICU and general ICU) and regions. Mortality was analysed with logistic regression.

RESULTS

A total of 1520 patients with aSAH from five regions were included in the study. Mean age of the patients were 60.6 years and 58% were female. Mortality within 180 days of admission was 30% (n = 456) of which 17% (n = 258) died during intensive care. A majority of the patients were treated at one hospital and in one ICU (70%, n = 1062). More than half of the patients (59%, n = 897) had their first intensive care admission at a hospital with a NICU. Patients in the North region had the lowest median GCS (10) and the highest SAPS3 score (60) when admitted to NICU. Treatment with invasive mechanical ventilation differed significantly between regions; 91% (n = 80) in the region with highest proportion versus 56% (n = 94) in the region with the lowest proportion, as did mortality; 16% (n = 44) versus 8% (n = 23). No differences between regions were found regarding age, sex and length of stay.

CONCLUSIONS

Patients with aSAH treated in a NICU or in an ICU in Sweden differs in characteristics. The study further showed some differences between regions which might be reduced if there were national consensus and treatment guidelines implemented.

Addressing the Evidence Gap in Aneurysmal Subarachnoid Hemorrhage: The Need for a Pragmatic Randomized Trial Platform

Aneurysmal subarachnoid hemorrhage (aSAH) occurs less often than other stroke types but affects younger patients, imposing a disproportionately high burden of long-term disability. Although management advances have improved outcomes over time, relatively few aSAH treatments have been tested in randomized clinical trials (RCTs). One lesson learned from COVID-19 is that trial platforms can facilitate the efficient execution of multicenter RCTs even in complex diseases during challenging conditions. An aSAH trial platform with standardized eligibility criteria, randomization procedures, and end point definitions would enable the study of multiple targeted interventions in a perpetual manner, with treatments entering and leaving the platform based on predefined decision algorithms. An umbrella institutional review board protocol and clinical trial agreement would allow individual arms to be efficiently added as amendments rather than stand-alone protocols. Standardized case report forms using the National Institutes of Health/National Institute of Neurological Disorders and Stroke common data elements and general protocol standardization across arms would create synergies for data management and monitoring. A Bayesian analysis framework would emphasize frequent interim looks to enable early termination of trial arms for futility, common controls, borrowing of information across arms, and adaptive designs. A protocol development committee would assist investigators and encourage pragmatic designs to maximize generalizability, reduce site burden, and execute trials efficiently and cost-effectively. Despite decades of steady clinical progress in the management of aSAH, poor patient outcomes remain common, and despite the increasing availability of RCT data in other fields, it remains difficult to perform RCTs to guide more effective care for aSAH. The development of a platform for pragmatic RCTs in aSAH would help close the evidence gap between aSAH and other stroke types and improve outcomes for this important disease with its disproportionate public health burden.

Clip versus coil shift for aneurysm treatment in Brazil: an exploratory analysis of trends in a 10-year time-series

Regarding intracranial aneurysm treatment, the clip versus coil debate remains inconclusive and lacking studies in Brazil. To examine trends in the management of intracranial aneurysms in Brazil over time, both ruptured and unruptured. A descriptive and exploratory study was conducted based on data of neurovascular procedures for aneurysm treatment using the Brazilian Public Health System database (DATASUS). The variables analyzed were the number of procedures, mortality rates, length of hospital stays, and global costs of hospitalization, from 2010 to 2019. Temporal trend analysis and statistical comparisons were conducted to assess changes over time and differences between the treatment options. The mean annual number of aneurysm treatments with endovascular embolization was 2206.30 (± 309.5), with a non-significant increasing trend (B = 55.66; p = 0.104). Conversely, microsurgical clipping exhibited a significant decreasing trend (B = -69.97; p < 0.001) with a mean of 1133.1 (± 223.12) procedures. The mortality rate associated with clipping procedure was higher in the period, with a mean difference of 5.23 (± 0.39); ([CI95%: 4.36; 6.10]; p < 0.001) and showed an increase trend, while embolization showed a stable trend. The length of in-hospital stay remained stable for clipping but increased for embolization. Costs associated with clipping increased over time, whereas costs for embolization decreased. This study highlights a significant shift in the treatment of aneurysm towards Endovascular Embolization. Despite higher costs, endovascular procedures were associated with lower mortality rates and shorter hospital stays. These findings provide valuable insights into aneurysm treatment patterns and indicators in a middle-income country's Public Health System.

Prevention of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage-Summary of Existing Clinical Evidence

The 2023 International Subarachnoid Hemorrhage Conference identified a need to provide an up-to-date review on prevention methods for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage and highlight areas for future research. A PubMed search was conducted for key factors contributing to development of delayed cerebral ischemia: anesthetics, antithrombotics, cerebrospinal fluid (CSF) diversion, hemodynamic, endovascular, and medical management. It was found that there is still a need for prospective studies analyzing the best methods for anesthetics and antithrombotics, though inhaled anesthetics and antiplatelets were found to have some advantages. Lumbar drains should increasingly be considered the first line of CSF diversion when applicable. Finally, maintaining euvolemia before and during vasospasm is recommended as there is no evidence supporting prophylactic spasmolysis or angioplasty. There is accumulating observational evidence, however, that intra-arterial spasmolysis with refractory DCI might be beneficial in patients not responding to induced hypertension. Nimodipine remains the medical therapy with the most support for prevention.

Rapid Ventricular Pacing for Clipping of Intracranial Aneurysms: A Single-centre Retrospective Case Series

OBJECTIVE

Multiple strategies exist to facilitate microdissection and obliteration of intracranial aneurysms during microsurgical clipping. Rapid ventricular pacing (RVP) can be used to induce controlled transient hypotension to facilitate aneurysm manipulation. We report the indications and outcomes of intraoperative RVP for clipping of ruptured and unruptured complex aneurysms.

METHODS

We completed a retrospective review of adult patients who underwent RVP-facilitated elective and emergent microsurgical aneurysm clipping by a single senior neurosurgeon between 2016 and 2023. Intraoperative RVP was performed at a rate of 150 to 200 beats per minute through a transvenous pacing wire and repeated as needed based on surgical requirements. Intraoperative procedural and pacing data and perioperative cardiac and neurosurgical variables were collected.

RESULTS

Forty patients were included in this study. The median (interquartile range) number of pacing episodes per patient was 8 (5 to 14), resulting in a median mean arterial pressure of 37 (30 to 40) mm Hg during RVP. One patient developed wide complex tachycardia intraoperatively, which resolved after cardioversion. Fifteen out of 36 (42%) patients who had postoperative troponin measurements had at least one troponin value above the 99th percentile upper reference limit. One patient had markedly elevated troponin with anterolateral ischemia in the context of massive postoperative intracranial hemorrhage. There were no other documented intraoperative or postoperative cardiac events.

CONCLUSIONS

This retrospective case series suggests that RVP could be an effective adjunct for clipping of complex ruptured and unruptured aneurysms, associated with transient troponin rise but rare postoperative cardiac complications.

Oxygen-Based Autoregulation Indices Associated with Clinical Outcomes and Spreading Depolarization in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Impairment in cerebral autoregulation has been proposed as a potentially targetable factor in patients with aneurysmal subarachnoid hemorrhage (aSAH); however, there are different continuous measures that can be used to calculate the state of autoregulation. In addition, it has previously been proposed that there may be an association of impaired autoregulation with the occurrence of spreading depolarization (SD) events.

METHODS

Study participants with invasive multimodal monitoring and aSAH were enrolled in an observational study. Autoregulation indices were prospectively calculated from this database as a 10 s moving correlation coefficient between various cerebral blood flow (CBF) surrogates and mean arterial pressure (MAP). In study participants with subdural electrocorticography (ECoG) monitoring, SD was also scored. Associations between clinical outcomes using the modified Rankin scale and occurrence of either isolated or clustered SD were assessed.

RESULTS

A total of 320 study participants were included, 47 of whom also had ECoG SD monitoring. As expected, baseline severity factors, such as modified Fisher scale score and World Federation of Neurosurgical Societies scale grade, were strongly associated with the clinical outcome. SD probability was related to blood pressure in a triphasic pattern, with a linear increase in probability below MAP of ~ 100 mm Hg. Multiple autoregulation indices were available for review based on moving correlations between mean arterial pressure (MAP) and various surrogates of cerebral blood flow (CBF). We calculated the pressure reactivity (PRx) using two different sources for intracranial pressure (ICP). We calculated the oxygen reactivity (ORx) using the partial pressure of brain tissue oxygen (PbtO2) from the Licox probe. We calculated the cerebral blood flow reactivity (CBFRx) using perfusion measurements from the Bowman perfusion probe. Finally, we calculated the cerebral oxygen saturation reactivity (OSRx) using regional cerebral oxygen saturation measured by near-infrared spectroscopy from the INVOS sensors. Only worse ORx and OSRx were associated with worse clinical outcomes. Both ORx and OSRx also were found to increase in the hour prior to SD for both sporadic and clustered SD.

CONCLUSIONS

Impairment in autoregulation in aSAH is associated with worse clinical outcomes and occurrence of SD when using ORx and OSRx. Impaired autoregulation precedes SD occurrence. Targeting the optimal MAP or cerebral perfusion pressure in patients with aSAH should use ORx and/or OSRx as the input function rather than intracranial pressure.

Fasudil hydrochloride and ozagrel sodium combination therapy for patients with aneurysmal subarachnoid hemorrhage: a cross-sectional study using a nationwide inpatient database

BACKGROUND

Fasudil and ozagrel are drugs with the same indications for the treatment of cerebral vasospasm in Japan. However, there have been no definitive conclusions on the clinical efficacy of fasudil hydrochloride and ozagrel sodium monotherapy or their combination. Therefore, we aimed to investigate the effectiveness of the combined administration of fasudil hydrochloride and ozagrel sodium in Japanese patients with subarachnoid hemorrhage (SAH).

METHODS

This cross-sectional study used Diagnosis Procedure Combination data to assess patients who were hospitalized with SAH and received fasudil hydrochloride or ozagrel sodium between April 2016 and March 2020 (n = 17,346). The participants were divided into three groups based on the treatment received: fasudil hydrochloride monotherapy (F group, n = 10,484), ozagrel sodium monotherapy (O group, n = 465), and fasudil hydrochloride and ozagrel sodium combination therapy (FO group, n = 6,397). The primary outcome was in-hospital mortality. Multivariable adjusted logistic regression analysis (significance level, 5%) was used for data analyses.

RESULTS

The results of the multivariable analysis, adjusted for factors considered to impact prognosis, showed that the adjusted odds ratio (OR) with the F group as the reference for in-hospital mortality was 0.94 in the FO group (95% confidence interval [CI]: 0.81-1.08, p = 0.355), with no differences compared to the F group.

CONCLUSION

Fasudil hydrochloride and ozagrel sodium had different mechanisms of action, suggesting a synergistic effect of combination therapy. However, a comparison of fasudil hydrochloride monotherapy and combination therapy of fasudil hydrochloride and ozagrel sodium showed no difference in the prognostic effect. Therefore, it was suggested that fasudil hydrochloride monotherapy may be sufficient.

Rationale and Design for the BLOCK-SAH Study (Pterygopalatine Fossa Block as an Opioid-Sparing Treatment for Acute Headache in Aneurysmal Subarachnoid Hemorrhage): A Phase II, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial with a Sequential Parallel Comparison Design

BACKGROUND

Acute post-subarachnoid hemorrhage (SAH) headaches are common and severe. Management strategies for post-SAH headaches are limited, with heavy reliance on opioids, and pain control is overall poor. Pterygopalatine fossa (PPF) nerve blocks have shown promising results in treatment of acute headache, including our preliminary and published experience with PPF-blocks for refractory post-SAH headache during hospitalization. The BLOCK-SAH trial was designed to assess the efficacy and safety of bilateral PPF-blocks in awake patients with severe headaches from aneurysmal SAH who require opioids for pain control and are able to verbalize pain scores.

METHODS

BLOCK-SAH is a phase II, multicenter, randomized, double-blinded, placebo-controlled clinical trial using the sequential parallel comparison design (SPCD), followed by an open-label phase.

RESULTS

Across 12 sites in the United States, 195 eligible study participants will be randomized into three groups to receive bilateral active or placebo PPF-injections for 2 consecutive days with periprocedural monitoring of intracranial arterial mean flow velocities with transcranial Doppler, according to SPCD (group 1: active block followed by placebo; group 2: placebo followed by active block; group 3: placebo followed by placebo). PPF-injections will be delivered under ultrasound guidance and will comprise 5-mL injectates of 20 mg of ropivacaine plus 4 mg of dexamethasone (active PPF-block) or saline solution (placebo PPF-injection).

CONCLUSIONS

The trial has a primary efficacy end point (oral morphine equivalent/day use within 24 h after each PPF-injection), a primary safety end point (incidence of radiographic vasospasm at 48 h from first PPF-injection), and a primary tolerability end point (rate of acceptance of second PPF-injection following the first PPF-injection). BLOCK-SAH will inform the design of a phase III trial to establish the efficacy of PPF-block, accounting for different headache phenotypes.

Efficacy and Safety of Early Treatment with Glibenclamide in Patients with Aneurysmal Subarachnoid Hemorrhage: A Randomized Controlled Trial

BACKGROUND

This study aims to investigate the efficacy and safety of glibenclamide treatment in patients with acute aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

The randomized controlled trial was conducted from October 2021 to May 2023 at two university-affiliated hospitals in Beijing, China. The study included patients with aSAH within 48 h of onset, of whom were divided into the intervention group and the control group according to the random number table method. Patients in the intervention group received glibenclamide tablet 3.75 mg/day for 7 days. The primary end points were the levels of serum neuron-specific enolase (NSE) and soluble protein 100B (S100B) between the two groups. Secondary end points included evaluating changes in the midline shift and the gray matter-white matter ratio, as well as assessing the modified Rankin Scale scores during follow-up. The trial was registered at ClinicalTrials.gov (identifier NCT05137678).

RESULTS

A total of 111 study participants completed the study. The median age was 55 years, and 52% were women. The mean admission Glasgow Coma Scale was 10, and 58% of the Hunt-Hess grades were no less than grade III. The baseline characteristics of the two groups were similar. On days 3 and 7, there were no statistically significant differences observed in serum NSE and S100B levels between the two groups (P > 0.05). The computer tomography (CT) values of gray matter and white matter in the basal ganglia were low on admission, indicating early brain edema. However, there were no significant differences found in midline shift and gray matter-white matter ratio (P > 0.05) between the two groups. More than half of the patients had a beneficial outcome (modified Rankin Scale scores 0-2), and there were no statistically significant differences between the two groups. The incidence of hypoglycemia in the two groups were 4% and 9%, respectively (P = 0.439).

CONCLUSIONS

Treating patients with early aSAH with oral glibenclamide did not decrease levels of serum NSE and S100B and did not improve the poor 90-day neurological outcome. In the intervention group, there was a visible decreasing trend in cases of delayed cerebral ischemia, but no statistically significant difference was observed. The incidence of hypoglycemia did not differ significantly between the two groups.

A nomogram model for predicting postoperative prognosis in patients with aneurysmal subarachnoid hemorrhage using preoperative biochemical indices

OBJECTIVE

The nutritional status and inflammatory responses of patients with aneurysmal subarachnoid hemorrhage (aSAH) play a vital prognostic role. We investigated the relationship between preoperative prognostic nutritional index (PNI)、neutrophil/albumin ratio (NAR)、platelet/albumin ratio (PAR) and other factors and the clinical prognosis of patients who underwent clipping for aSAH and its predictive model.

METHODS

The clinical data of 212 patients with aSAH who underwent neurosurgery at Nanyang Central Hospital between 2018 and 2023 were retrospectively analyzed. Based on the Glasgow Outcome Scale (GOS) score at 6 months postoperatively, the patients were categorized into two groups: poor (GOSI-III) and good (GOSIV-V) prognosis groups. Multivariate logistic regression analysis was performed to determine the predictive value of preoperative PNI、NAR、PAR、hyperlipidemia and Glasgow Coma Scale (GCS) for prognosis. Furthermore, nomograms and prognostic prediction models were constructed. Receiver operating characteristic curves and area under the curve (AUC) were utilized to determine the predictive values.

RESULTS

Multivariate logistic regression analysis revealed that PNI (OR = 1.250, 95%CI 1.060 ~ 1.475, P = 0.008), NAR (OR = 0.000, 95%CI 0.000 ~ 0.004, P = 0.000), PAR(OR = 0.515, 95%CI 0.283 ~ 0.937, P = 0.030), hyperlipidemia (OR = 4.627, 95%CI 1.166 ~ 18.367, P = 0.029), and GCS(OR = 1.446, 95%CI 1.041 ~ 2.008, P = 0.028) are independent risk factors for poor postoperative prognosis. The total score of the nomogram was 200, and the AUC value was 0.972.

CONCLUSIONS

PNI and NAR can reflect the nutritional status and inflammatory responses of patients.They are significantly associated with the postoperative prognosis of patients with aSAH. Comprehensively analyzing PNI and NAR combined with other clinical indicators can more effectively guide treatment and help predict prognosis.

Microsurgical clipping of large MCA aneurysm in a 2-month-old child

BACKGROUND

Cerebral aneurysms in children have a low incidence and accounts for less than 4% of all cerebral aneurysms. These aneurysms have been linked to various factors. Severe headache, seizures, and motor-sensory deficits are common presentations.

CASE REPORT

We describe the case of a 2-month-old male patient who presented with generalized tonic-clonic seizures for 4 days. At the hospital, he was stabilized with ventilatory support, sedation, and antiepileptic drugs. A NCCT (Head) showed intraparenchymal hemorrhage in the left fronto-parieto-temporal lobe and subarachnoid hemorrhage. Subsequently a CT angiogram revealed an aneurysm of the left M3 segment of MCA. Successfully, the patient underwent microsurgical clipping of aneurysm and evacuation of hematoma.

CONCLUSIONS

Pediatric cerebral aneurysms differ from their adult counterparts, mainly in their etiology and evolution. As per literature, aneurysmal clipping and neurological endovascular therapy have shown similar results.

Considering Adverse Effects of Common Antihypertensive Medications in the ED

PURPOSE OF REVIEW

To evaluate the adverse effects of common antihypertensive agents utilized or encountered in the Emergency Department.

RECENT FINDINGS

All categories of antihypertensive agents may manifest adverse effects, inclusive of adverse drug reactions (ADRs), drug-to-drug interactions, or accidental overdose. Adverse effects, and specifically ADRs, may be stratified into the organ systems affected, might require specific time-sensitive interventions, could pose particular risks to vulnerable populations, and may result in significant morbidity, and potential mortality. Adverse effects of common antihypertensive agents may be encountered in the ED, necessitating that ED systems of care are poised to prevent, recognize, and intervene when adverse effects arise.

Safety and Effect on Intracranial Pressure of 3% Hypertonic Saline Bolus Via Peripheral Intravenous Catheter for Neurological Emergencies

BACKGROUND

Elevated intracranial pressure (ICP) is a neurological emergency in patients with acute brain injuries. Such a state requires immediate and effective interventions to prevent potential neurological deterioration. Current clinical guidelines recommend hypertonic saline (HTS) and mannitol as first-line therapeutic agents. Notably, HTS is conventionally administered through central venous catheters (CVCs), which may introduce delays in treatment due to the complexities associated with CVC placement. These delays can critically affect patient outcomes, necessitating the exploration of more rapid therapeutic avenues. This study aimed to investigate the safety and effect on ICP of administering rapid boluses of 3% HTS via peripheral intravenous (PIV) catheters.

METHODS

A retrospective cohort study was performed on patients admitted to Sisters of Saint Mary Health Saint Louis University Hospital from March 2019 to September 2022 who received at least one 3% HTS bolus via PIV at a rate of 999 mL/hour for neurological emergencies. Outcomes assessed included complications related to 3% HTS bolus and its effect on ICP.

RESULTS

Of 216 3% HTS boluses administered in 124 patients, complications occurred in 8 administrations (3.7%). Pain at the injection site (4 administrations; 1.9%) and thrombophlebitis (3 administrations; 1.4%) were most common. The median ICP reduced by 6 mm Hg after 3% HTS bolus administration (p < 0.001).

CONCLUSIONS

Rapid bolus administration of 3% HTS via PIV catheters presents itself as a relatively safe approach to treat neurological emergencies. Its implementation could provide an invaluable alternative to the traditional CVC-based administration, potentially minimizing CVC-associated complications and expediting life-saving interventions for patients with neurological emergencies, especially in the field and emergency department settings.

Cognitive, Mental Health, Functional, and Quality of Life Outcomes 1 Year After Spontaneous Subarachnoid Hemorrhage: A Prospective Observational Study

BACKGROUND

Patients with spontaneous subarachnoid hemorrhage (SAH) frequently encounter cognitive dysfunction and mental health issues with negative effects on health-related quality of life (HR-QoL). Here, we aimed to describe the prevalence of cognitive deficits, mental health problems, and HR-QoL impairments 1 year after SAH.

METHODS

In this prospective observational study, 177 patients with SAH admitted to our neurointensive care unit over a time span of ten years followed the invitation for an in-person 1-year follow-up, including a standardized neuropsychological test battery. Mental health issues (anxiety and depression) and HR-QoL were evaluated using questionnaires (Hospital Anxiety and Depression Scale; 36-item Short Form questionnaire). Functional outcome was assessed with the modified Rankin Scale (mRS) score.

RESULTS

Patients were 54 years of age (interquartile range 47-62 years) and presented with a median Hunt and Hess score of 2 (interquartile range 1-3) at admission. Most patients (93%) achieved good functional 1-year outcomes (mRS score 0-2). Seventy-one percent of patients had deficits in at least one cognitive domain, with memory deficits being the most prevalent (51%), followed by deficits in executive functions (36%), visuoconstruction (34%), and attention (21%). Even patients with perimesencephalic SAH (18%) or with full functional recovery (mRS score = 0, 46%) had a comparable prevalence of cognitive deficits (61% and 60%, respectively). Symptoms of depression and anxiety were reported by 16% and 33% of patients, respectively. HR-QoL was impaired in 37% (55 of 147). Patients with cognitive deficits (p = 0.001) or mental health issues (p < 0.001) more frequently reported impaired HR-QoL.

CONCLUSIONS

Most patients with SAH have cognitive deficits and mental health issues 1 year after SAH. These deficits impair patients' quality of life.

Characteristics of a Pure Acute Subdural Hematoma Caused by Intracranial Aneurysm Rupture: A Case Report and Review of Literature

Pure acute subdural hematomas (ASDHs) due to ruptured aneurysms without subarachnoid or intracerebral hemorrhage are rare. We report the case of a 26-year-old female who presented with a pure ASDH caused by a ruptured distal anterior cerebral artery (ACA). The patient complained of sudden headache and vomiting and was transferred to our hospital. On the ambulance journey to the hospital, her consciousness level decreased suddenly just after experiencing additional pain in the head. At admission, the consciousness level was 4 points on the Glasgow coma scale with bilateral pupil dilatation. Computed tomography (CT) and CT angiography showed a left ASDH without subarachnoid hemorrhage (SAH) and a distal ACA aneurysm. Emergent hematoma evacuation was performed, but SAH and the bleeding point were not observed. Therefore, coil embolization for the distal ACA aneurysm was performed after an emergent operation. During embolization, intraoperative rupture was observed. The contrast media was seen up to the convexity subdural space along the falx. Extravasation ceased after intraaneurysmal coil embolization. Consequently, the rupture of the distal ACA aneurysm was diagnosed as the cause of the pure ASDH. The patient received additional coil embolization due to recanalization of the aneurysm without rebleeding 44 days after admission and was transferred to a rehabilitation hospital 55 days after admission to our hospital with a score of 4 on the modified ranking scale. From the reviews of 56 patients from 32 studies, including our case, we determine that an ACA aneurysm could show the distant hematomas located far from the site of a ruptured aneurysm compared with a ruptured aneurysm located in the internal carotid and middle cerebral arteries. Distant hematoma location could also lead to delayed diagnosis of aneurysms and lead to rebleeding and poor outcomes. Aneurysm rupture diagnoses should receive special attention, especially for ACA aneurysms, as the hematoma may be located far from the rupture site.

Single-Dose Calcium Channel Blocker Toxicity in a Patient With Severe Liver Disease

Calcium channel blockers (CCBs) are commonly used in the management of multiple diseases, including hypertension, arrhythmia, and vasospastic disorder. Nimodipine, a dihydropyridine CCB, has demonstrated utility in preserving hearing following vestibular schwannoma resection surgery. Due to its widespread use, CCB overdose is common. This case report presents a unique case of CCB toxicity in a 56-year-old female with end-stage liver dysfunction. The patient developed vasodilatory shock after receiving a single dose of prophylactic nimodipine following vestibular schwannoma surgery. The primary objective of this report is to highlight the unique risk for CCB toxicity that exists for patients with advanced liver disease who receive nimodipine in the perioperative setting.

Advances and Future Trends in the Diagnosis and Management of Subarachnoid Hemorrhage

Major advances in neurocritical care and the modalities used to treat aneurysms have led to improvement in the outlook of patients with aneurysmal subarachnoid hemorrhage. Yet, several knowledge gaps remain widely open. Variability in practices stems from the lack of solid evidence to guide management, which recent guidelines from professional organizations aim to mitigate. In this article, the authors review some of these gaps in knowledge, highlight important messages from recent management guidelines, emphasize aspects of our practice that we consider particularly useful to optimize patient outcomes, and suggest future areas of research.