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Zhou Y, Wang K, Li R, Lin F, Chen Y, Yang J, Han H, Li T, Jia Y, Yuan K, Zhang H, Li R, Li Z, Li C, Zhao Y, Hao Q, Chen X, Zhao Y. Dynamic changes of platelets before and after surgery predict the prognosis of patients with aneurysmal subarachnoid hemorrhage. Heliyon 2024; 10:e37706. [PMID: 39381250 PMCID: PMC11458939 DOI: 10.1016/j.heliyon.2024.e37706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 09/02/2024] [Accepted: 09/09/2024] [Indexed: 10/10/2024] Open
Abstract
Objective This investigation explored the association between postoperative/preoperative platelet ratio (PPR) and the incidence of unfavorable outcomes within 90 days in individuals with aneurysmal subarachnoid hemorrhage (aSAH). Methods This investigation, utilizing data from 2015 to 2022, concentrated on patients diagnosed with aSAH, categorizing them into four groups based on PPR quartiles. The association between PPR levels and clinical outcomes-comprising in-hospital complications, mortality, and modified Rankin Scale (mRS) scores at discharge and 90 days after that-was evaluated through logistic regression analyses. To explore potential non-linear associations between PPR levels and outcomes, restricted cubic spline (RCS) regression was applied. Further, mediation analysis was performed to elucidate the role of in-hospital complications in modulating the impact of PPR levels on 90-day outcomes. Results This study analyzed data from 948 patients. Upon adjustment for confounding variables, it was observed that patients in the higher quartiles showed reduced incidences of anemia, hypoproteinemia, and pneumonia, alongside a decreased frequency of unfavorable outcomes within a 90-day follow-up period. The RCS analysis indicated a linear association of PPR with pneumonia, hypoproteinemia, and adverse 90-day outcomes (p for nonlinear = 0.61, 0.52, and 0.96, respectively). Moreover, the association of PPR with anemia was found to be nonlinear (p for nonlinear = 0.01). Mediation analysis further indicated that anemia and pneumonia significantly influenced the association between PPR and unfavorable outcomes at 90 days, accounting for 15.49 % and 27.61 % of the effect, respectively. Conclusions This study establishes a significant correlation between decreased PPR levels and 90-day adverse outcomes following aSAH, potentially relating to pneumonia and anemia.
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Affiliation(s)
- Yunfan Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tu Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yitong Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cunyang Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yahui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
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Truckenmueller P, Wolf S, Wasilewski D, Vajkoczy P, Früh A. Association of Fluid Balance and Hemoglobin Decline With Neurological Outcome After Aneurysmal Subarachnoid Hemorrhage. Crit Care Med 2024; 52:1391-1401. [PMID: 38775857 PMCID: PMC11321606 DOI: 10.1097/ccm.0000000000006332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
OBJECTIVES To explore the relationship between fluid balance and hemoglobin decline with secondary infarctions and neurologic outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients. DESIGN Secondary analysis of the Earlydrain trial, a prospective randomized controlled study investigating prophylactic lumbar drain use in aSAH patients. SETTING Patients with aSAH treated in ICUs at 19 tertiary hospitals in Germany, Switzerland, and Canada. PATIENTS From January 2011 to January 2016, 287 patients were enrolled in the Earlydrain trial. Only files with complete information on both daily hemoglobin and balance values were used, leaving 237 patients for analysis. INTERVENTIONS Investigation of fluid balance management and hemoglobin levels during the initial 8 days post-aSAH to establish thresholds for unfavorable outcomes and assess their impact on secondary infarctions and 6-month neurologic outcome on the modified Rankin Scale (mRS). MEASUREMENTS AND MAIN RESULTS Patients with unfavorable outcome after 6 months (mRS > 2) showed greater hemoglobin decline and increased cumulative fluid balance. A significant inverse relationship existed between fluid balance and hemoglobin decline. Thresholds for unfavorable outcome were 10.4 g/dL hemoglobin and 4894 mL cumulative fluid balance in the first 8 days. In multivariable analysis, fluid balance, but not fluid intake, remained significantly associated with unfavorable outcome, while the influence of hemoglobin lessened. Fluid balance but not hemoglobin related to secondary infarctions, with the effect being significant after inverse probability of treatment weighting. Transfusion was associated with unfavorable outcomes. CONCLUSIONS Increased fluid balance influences hemoglobin decline through hemodilution. Fluid overload, rather than a slight decrease in hemoglobin levels, appears to be the primary factor contributing to poor outcomes in aSAH patients. The results suggest aiming for euvolemia and that a modest hemoglobin decline may be tolerated. It may be advisable to adopt a restrictive approach to transfusions, as they can potentially have a negative effect on outcome.
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Affiliation(s)
- Peter Truckenmueller
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - David Wasilewski
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Anton Früh
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Berlin, Germany
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Wu F, Chen H, Liu Z, Ye D, Wang X, Zhou L, Xu Z, Wang D, Shen J, Zhan R, Zhu Y. Predicting postacute phase anaemia after aneurysmal subarachnoid haemorrhage: nomogram development and validation. BMJ Open 2024; 14:e082799. [PMID: 39025815 PMCID: PMC11261674 DOI: 10.1136/bmjopen-2023-082799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 07/07/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Anaemia is a severe and common complication in patients with aneurysmal subarachnoid haemorrhage (aSAH). Early intervention for at-risk patients before anaemia occurs is indicated as potentially beneficial, but no validated method synthesises patients' complicated clinical features into an instrument. The purpose of the current study was to develop and externally validate a nomogram that predicted postacute phase anaemia after aSAH. METHODS We developed a novel nomogram for aSAH patients to predict postacute phase anaemia (3 days after occurrence of aSAH, prior to discharge) on the basis of demographic information, imaging, type of treatment, aneurysm features, blood tests and clinical characteristics. We designed the model from a development cohort and tested the nomogram in external and prospective validation cohorts. We included 456 aSAH patients from The First Affiliated Hospital for the development, 220 from Sanmen People's Hospital for external validation and a prospective validation cohort that included 13 patients from Hangzhou Red Cross Hospital. We assessed the performance of the nomogram via concordance statistics and evaluated the calibration of predicted anaemia outcome with observed anaemia occurrence. RESULTS Variables included in the nomogram were age, treatment method (open surgery or endovascular therapy), baseline haemoglobin level, fasting blood glucose level, systemic inflammatory response syndrome score on admission, Glasgow Coma Scale score, aneurysm size, prothrombin time and heart rate. In the validation cohort, the model for prediction of postacute phase anaemia had a c-statistic of 0.910, with satisfactory calibration (judged by eye) for the predicted and reported anaemia outcome. Among forward-looking forecasts, our predictive model achieved an 84% success rate, which showed that it has some clinical practicability. CONCLUSIONS The developed and validated nomogram can be used to calculate individualised anaemia risk and has the potential to serve as a practical tool for clinicians in devising improved treatment strategies for aSAH.
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Affiliation(s)
- Fan Wu
- Neurosurgery, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Huai Chen
- Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Zongchi Liu
- Neurosurgery, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Di Ye
- Neurosurgery, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Xiaoyi Wang
- Neurosurgery, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Lihui Zhou
- Neurosurgery, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Zihan Xu
- Neurosurgery, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Duanbu Wang
- Department of Neurosurgery, Sanmen People’s Hospital, Sanmen, China
| | - Jian Shen
- Neurosurgery, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Renya Zhan
- Neurosurgery, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Yu Zhu
- Neurosurgery, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
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Roh DJ, Poyraz FC, Mao E, Shen Q, Kansara V, Cottarelli A, Song S, Nemkov T, Kumar A, Hudson KE, Ghoshal S, Park S, Agarwal S, Connolly ES, Claassen J, Kreuziger LB, Hod E, Yeatts S, Foster LD, Selim M. Anemia From Inflammation After Intracerebral Hemorrhage and Relationships With Outcome. J Am Heart Assoc 2024; 13:e035524. [PMID: 38979830 PMCID: PMC11292775 DOI: 10.1161/jaha.124.035524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/11/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Baseline anemia is associated with poor intracerebral hemorrhage (ICH) outcomes. However, underlying drivers for anemia and whether anemia development after ICH impacts clinical outcomes are unknown. We hypothesized that inflammation drives anemia development after ICH and assessed their relationship to outcomes. METHODS AND RESULTS Patients with serial hemoglobin and iron biomarker concentrations from the HIDEF (High-Dose Deferoxamine in Intracerebral Hemorrhage) trial were analyzed. Adjusted linear mixed models assessed laboratory changes over time. Of 42 patients, significant decrements in hemoglobin occurred with anemia increasing from 19% to 45% by day 5. Anemia of inflammation iron biomarker criteria was met in 88%. A separate cohort of 521 patients with ICH with more granular serial hemoglobin and long-term neurological outcome data was also investigated. Separate regression models assessed whether (1) systemic inflammatory response syndrome (SIRS) scores related to hemoglobin changes over time and (2) hemoglobin changes related to poor 90-day outcome. In this cohort, anemia prevalence increased from 30% to 71% within 2 days of admission yet persisted beyond this time. Elevated systemic inflammatory response syndrome was associated with greater hemoglobin decrements over time (adjusted parameter estimate: -0.27 [95% CI, -0.37 to -0.17]) and greater hemoglobin decrements were associated with poor outcomes (adjusted odds ratio per 1 g/dL increase, 0.76 [95% CI, 0.62-0.93]) independent to inflammation and ICH severity. CONCLUSIONS We identified novel findings that acute anemia development after ICH is common, rapid, and related to inflammation. Because anemia development is associated with poor outcomes, further work is required to clarify if anemia, or its underlying drivers, are modifiable treatment targets that can improve ICH outcomes. REGISTRATION https://www.clinicaltrials.gov Unique identifier: NCT01662895.
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Affiliation(s)
- David J. Roh
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Fernanda Carvalho Poyraz
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Eric Mao
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Qi Shen
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Vedant Kansara
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Azzurra Cottarelli
- Department of Pathology and Cell BiologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Sandy Song
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Travis Nemkov
- Department of Biochemistry and Molecular GeneticsUniversity of Colorado Denver Anschutz Medical CampusAuroraCOUSA
| | - Aditya Kumar
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Krystalyn E. Hudson
- Department of Pathology and Cell BiologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Shivani Ghoshal
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Soojin Park
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Sachin Agarwal
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Edward Sander Connolly
- Department of Neurological SurgeryVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Jan Claassen
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Lisa Baumann Kreuziger
- Versiti Blood Research InstituteVersiti; Department of MedicineDivision of Hematology and OncologyMedical College of WisconsinMilwaukeeWIUSA
| | - Eldad Hod
- Department of Pathology and Cell BiologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Sharon Yeatts
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSCUSA
| | - Lydia D. Foster
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSCUSA
| | - Magdy Selim
- Department of NeurologyBeth Israel DeaconnessBostonMAUSA
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5
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Wang X, Gan Q, Qiu X, Chen W, Wen D, You C, Ma L. Association of hemoglobin drift and outcomes in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2024; 47:310. [PMID: 38985351 DOI: 10.1007/s10143-024-02546-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 05/07/2024] [Accepted: 06/30/2024] [Indexed: 07/11/2024]
Abstract
The relationship between in-hospital hemoglobin (Hb) drift and outcomes in patients undergoing surgical clipping for aneurysmal subarachnoid hemorrhage (aSAH) is not well studied. This study aims to investigate the association between Hb drift and mortality in this patient population. We conducted a cohort study encompassing adult patients diagnosed with aSAH who were admitted to a university hospital. These patients were stratified into distinct groups based on their Hb drift levels. We employed logistic and Cox proportional hazard models to assess the relationship between Hb drift and outcomes. Additionally, propensity score matching (PSM) was utilized to ensure comparability between patient groups. The discriminative performance of different models was evaluated using C-statistics, integrated discrimination improvement (IDI), and net reclassification improvement (NRI). Overall, our cohort comprised 671 patients, of whom 165 (24.6%) demonstrated an in-hospital Hb drift exceeding 25%. The analyses revealed elevated Hb drift was independently associated with higher likelihood of follow-up mortality (aOR: 3.29, 95% CI: 1.65 to 6.56; P = 0.001) and in-hospital mortality (aOR: 3.44, 95% CI: 1.55 to 7.63; P = 0.002). PSM analysis yielded similar results. Additionally, patients with Hb drift exhibited a notable decrease in survival rate compared to those without Hb drift (aHR: 3.99, 95% CI 2.30 to 6.70; P < 0.001). Furthermore, the inclusion of Hb drift significantly improved the C-statistic (P = 0.037), IDI (2.78%; P = 0.004) and NRI metrics (41.86%; P < 0.001) for mortality prediction. In summary, our results highlight that an in-hospital Hb drift exceeding 25% serves as an independent predictor of mortality in patients who have undergone surgical clipping for aSAH.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Qi Gan
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Xingyu Qiu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Wuqian Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Dingke Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China
- West China Brain Center, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China.
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Peng K, Adegboro AA, Li Y, Liu H, Xiong B, Li X. The association between hematologic traits and aneurysm-related subarachnoid hemorrhage: a two-sample mendelian randomization study. Sci Rep 2024; 14:11694. [PMID: 38777813 PMCID: PMC11111675 DOI: 10.1038/s41598-024-62761-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 05/21/2024] [Indexed: 05/25/2024] Open
Abstract
Several hematologic traits have been suggested to potentially contribute to the formation and rupture of intracranial aneurysms (IA). The purpose of this study is to explore the causal association between hematologic traits and the risk of IA. To explore the causal association between hematologic traits and the risk of IA, we employed two-sample Mendelian randomization (MR) analysis. Two independent summary-level GWAS data were used for preliminary and replicated MR analyses. The inverse variance weighted (IVW) method was employed as the primary method in the MR analyses. The stabilities of the results were further confirmed by a meta-analysis. In the preliminary MR analysis, hematocrit, hemoglobin concentration (p = 0.0047), basophil count (p = 0.0219) had a suggestive inverse causal relationship with the risk of aneurysm-associated subarachnoid hemorrhage (aSAH). The monocyte percentage of white cells (p = 0.00956) was suggestively positively causally correlated with the risk of aSAH. In the replicated MR analysis, only the monocyte percentage of white cells (p = 0.00297) remained consistent with the MR results in the preliminary analysis. The hematocrit, hemoglobin concentration, and basophil count no longer showed significant causal relationship (p > 0.05). Meta-analysis results further confirmed that only the MR result of monocyte percentage of white cells reached significance in the random effect model and fixed effect model. None of the 25 hematologic traits was causally associated with the risk of unruptured intracranial aneurysms (uIA). This study revealed a suggestive positive association between the monocyte percentage of white cells and the risk of aSAH. This finding contributes to a better understanding that monocytes/macrophages could participate in the risk of aSAH.
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Affiliation(s)
- Kang Peng
- Department of Radiology, Xiangya Hospital, Central South University, 87 xiangya road, Changsha, Hunan, China
- Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China
| | - Abraham Ayodeji Adegboro
- Department of Neurosurgery, Xiangya Hospital, Central South University, 87 xiangya road, Changsha, Hunan, China
- Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China
| | - Yanwen Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, 87 xiangya road, Changsha, Hunan, China
- Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China
| | - Hongwei Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, 87 xiangya road, Changsha, Hunan, China
- Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China
| | - Biao Xiong
- Department of Neurosurgery, People's Hospital of Wangcheng District, Changsha, 410200, Hunan, China.
| | - Xuejun Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, 87 xiangya road, Changsha, Hunan, China.
- Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China.
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Ma K, Bebawy JF. Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature. Anesth Analg 2024; 138:992-1002. [PMID: 38109853 DOI: 10.1213/ane.0000000000006772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.
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Affiliation(s)
- Kan Ma
- From the Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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8
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Ryan D, Ikramuddin S, Alexander S, Buckley C, Feng W. Three Pillars of Recovery After Aneurysmal Subarachnoid Hemorrhage: A Narrative Review. Transl Stroke Res 2024:10.1007/s12975-024-01249-6. [PMID: 38602660 DOI: 10.1007/s12975-024-01249-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/12/2024]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurologic disease with high mortality and disability. There have been global improvements in survival, which has contributed to the prevalence of patients living with long-term sequelae related to this disease. The focus of active research has traditionally centered on acute treatment to reduce mortality, but now there is a great need to study the course of short- and long-term recovery in these patients. In this narrative review, we aim to describe the core pillars in the preservation of cerebral function, prevention of complications, the recent literature studying neuroplasticity, and future directions for research to enhance recovery outcomes following aSAH.
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Affiliation(s)
- Dylan Ryan
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27704, USA
| | - Salman Ikramuddin
- Department of Neurology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Sheila Alexander
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | | | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27704, USA.
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Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, Veenith T. Diagnosis and management of subarachnoid haemorrhage. Nat Commun 2024; 15:1850. [PMID: 38424037 PMCID: PMC10904840 DOI: 10.1038/s41467-024-46015-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
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.
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Affiliation(s)
- Suneesh Thilak
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Poppy Brown
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Tony Whitehouse
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nandan Gautam
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Errin Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK.
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Foundation Trust, New Cross Hospital, Wolverhampton, WV10 0QP, UK.
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Singh N, Sachdev S, Regmi S, Joys S, Jindal HA, Singh T, Maheshwari N, Mahajan S, Jangra K, Soni SL, Kaloria N, Luthra A, Chauhan R, Panda NB, Singh A, Bhagat H. Effect of Peri-operative Blood Transfusion on Neurological Outcome Following Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Study. Neurol India 2024; 72:58-63. [PMID: 38443002 DOI: 10.4103/ni.ni_1242_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 06/15/2022] [Indexed: 03/07/2024]
Abstract
BACKGROUND Anemia is a common complication of aneurysmal subarachnoid hemorrhage and is associated with unfavorable outcomes. Whether the physiological benefits of transfusion for anemia surpass the risk of blood transfusion remains to be determined. OBJECTIVES The primary outcome was to evaluate the impact of peri-operative blood transfusion on the long-term neurological outcome, assessed by Glasgow Outcome Scale Extended at 3 months. The secondary outcomes included the impact of transfusion on the short-term neurological outcome, assessed by Modified Rankin Score at discharge/7 days, and on the incidence of vasospasm, infarction, re-exploration, tracheostomy, and length of hospital stay. MATERIAL AND METHODS This prospective observational study was conducted on 185 patients with aneurysmal subarachnoid hemorrhage undergoing clipping of the aneurysmal neck. In our study, blood transfusion was administered to keep the target Hb around 10 g/dL. RESULTS Unfavorable long-term outcome was found in 27/97 (28%) of patients who received a blood transfusion as compared to 13/74 (18%) of patients who did not receive a transfusion (P = 0.116). Patients receiving transfusion had more chances of an unfavorable outcome at discharge/7 days as compared to those not transfused [44/103 (43%) versus 22/80 (27%)], P = 0.025. There were increased chances of vasospasm, infarction, re-exploration, tracheostomy, and increased length of hospital stay in patients receiving transfusion (P < 0.05). CONCLUSIONS The use of blood transfusion in patients with aneurysmal subarachnoid hemorrhage was associated with increased neurological complications and hence an unfavorable short-term outcome. However, when used judiciously as per the clinical requirements, blood transfusion did not have a significant effect on long-term neurological outcome.
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Affiliation(s)
- Nidhi Singh
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Suchet Sachdev
- Department of Transfusion Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sabina Regmi
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Steve Joys
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Har Ashish Jindal
- Department of Ministry of Health and Family Welfare, New Delhi, India
| | - Tania Singh
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Neha Maheshwari
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Shalvi Mahajan
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Kiran Jangra
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Shiv L Soni
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Narender Kaloria
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Ankur Luthra
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Nidhi Bidyut Panda
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
| | - Apinderpreet Singh
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, Division of Neuroanesthesia, Chandigarh, India
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11
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Hou H, Pang L, Zhao L, Liu Z, Xing JH. Hemoglobin as a prognostic marker for neurological outcomes in post-cardiac arrest patients: a meta-analysis. Sci Rep 2023; 13:18531. [PMID: 37898729 PMCID: PMC10613227 DOI: 10.1038/s41598-023-45818-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/24/2023] [Indexed: 10/30/2023] Open
Abstract
The aim of this study was to investigate the relationship between serum level of hemoglobin and neurological outcomes following cardiac arrest. Relevant studies were identified by searching electronic databases including PubMed, Web of Science, Cochrane Library, and Embase from June 2012 through April 2023. Articles were rigorously reviewed for their study inclusion and exclusion criteria. Pooled effect date was determined using the standardized mean difference (SMD) and 95% confidence intervals (CI). The Newcastle-Ottawa Scale was used to evaluate study quality. Subgroup analyses were conducted to determine confounding factors affecting patient outcomes. Study heterogeneity, sensitivity, and publication bias were also determined.This meta-analysis included 11 studies involving 2519 patients. Our results suggest that high serum level of hemoglobin may improve neurological prognosis(SMD = 0.60, 95%CI = 0.49-0.71, I2 = 10.85). The findings of this study indicate that serum level of hemoglobin may be associated with better neurological prognosis, perhaps an appropriate increase in serum haemoglobin levels can improve the neurological prognosis of patients in cardiac arrest.
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Affiliation(s)
- Hongxiang Hou
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China
| | - Li Pang
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China
| | - Liang Zhao
- Rehabilitation Department, the First Hospital of Jilin University, Changchun, China
| | - Zuolong Liu
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China
| | - Ji-Hong Xing
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China.
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12
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Terrett LA, McIntyre L, Turgeon AF, English SW. Anemia and Red Blood Cell Transfusion in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:91-103. [PMID: 37634181 DOI: 10.1007/s12028-023-01815-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 08/29/2023]
Abstract
Anemia is very common in aneurysmal subarachnoid hemorrhage (aSAH), with approximately half of the aSAH patient population developing moderate anemia during their hospital stay. The available evidence (both physiologic and clinical) generally supports an association of anemia with unfavorable outcomes. Although aSAH shares a number of common mechanisms of secondary insult with other forms of acute brain injury, aSAH also has specific features that make it unique: an early phase (in which early brain injury predominates) and a delayed phase (in which delayed cerebral ischemia and vasospasm predominate). The effects of both anemia and transfusion are potentially variable between these phases, which may have unique considerations and possibly different risk-benefit profiles. Data on transfusion in this population are almost exclusively limited to observational studies, which suffer from significant heterogeneity and risk of bias. Overall, the results are conflicting, with the balance of the studies suggesting that transfusion is associated with unfavorable outcomes. The transfusion targets that are well established in other critically ill populations should not be automatically applied to patients with aSAH because of the unique disease characteristics of this population and the limited representation of aSAH in the clinical trials that established these targets. There are two upcoming clinical trials evaluating transfusion in aSAH that should help clarify specific transfusion targets. Until then, it is reasonable to base transfusion decisions on the current guidelines and use an individualized approach incorporating physiologic and clinical data when available.
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Affiliation(s)
- Luke A Terrett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
- Department of Adult Critical Care, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute (OHRI), Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Unit, Centre hospitalier universitaire de Québec-Université Laval Research Center, Quebec City, QC, Canada
| | - Shane W English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute (OHRI), Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
- The Ottawa Hospital, Ottawa, ON, Canada.
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13
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Treggiari MM, Rabinstein AA, Busl KM, Caylor MM, Citerio G, Deem S, Diringer M, Fox E, Livesay S, Sheth KN, Suarez JI, Tjoumakaris S. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:1-28. [PMID: 37202712 DOI: 10.1007/s12028-023-01713-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/03/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology. METHODS The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the "Risk of Bias In Nonrandomized Studies - of Interventions" tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations. RESULTS The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation. CONCLUSIONS These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5692 HAFS, Box 3059, Durham, NC, 27710, USA.
| | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Department Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Steven Deem
- Neurocritical Care, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Michael Diringer
- Departments of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Elizabeth Fox
- Neurocritical Care, Stanford Health Care, Palo Alto, CA, USA
| | - Sarah Livesay
- Neurocritical Care, University of Washington, Seattle, WA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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14
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Shah VA, Gonzalez LF, Suarez JI. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:36-50. [PMID: 37231236 DOI: 10.1007/s12028-023-01747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.
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Affiliation(s)
- Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA.
| | - L Fernando Gonzalez
- Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA
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15
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Lukito PP, Lie H, Angelica V, Wijovi F, Nathania R, July J. Red-cell distribution width as a prognostic marker for aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. World Neurosurg X 2023; 19:100202. [PMID: 37181583 PMCID: PMC10172754 DOI: 10.1016/j.wnsx.2023.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/16/2023] Open
Affiliation(s)
- Patrick P. Lukito
- Department of Neurosurgery, Neuroscience Centre Siloam Hospital, Faculty of Medicine, Universitas Pelita Harapan, Jenderal Sudirman Boulevard, Lippo Karawaci, Tangerang, Banten, 15811, Indonesia
- Corresponding author.
| | - Hendry Lie
- Faculty of Medicine, Universitas Pelita Harapan, Jenderal Sudirman Boulevard, Lippo Karawaci, Tangerang, Banten, 15811, Indonesia
| | - Vanessa Angelica
- Faculty of Medicine, Universitas Pelita Harapan, Jenderal Sudirman Boulevard, Lippo Karawaci, Tangerang, Banten, 15811, Indonesia
| | - Felix Wijovi
- Faculty of Medicine, Universitas Pelita Harapan, Jenderal Sudirman Boulevard, Lippo Karawaci, Tangerang, Banten, 15811, Indonesia
| | - Regina Nathania
- Faculty of Medicine, Universitas Pelita Harapan, Jenderal Sudirman Boulevard, Lippo Karawaci, Tangerang, Banten, 15811, Indonesia
| | - Julius July
- Department of Neurosurgery, Neuroscience Centre Siloam Hospital, Faculty of Medicine, Universitas Pelita Harapan, Jenderal Sudirman Boulevard, Lippo Karawaci, Tangerang, Banten, 15811, Indonesia
- Corresponding author.
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16
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Nwafor DC, Kirby BD, Ralston JD, Colantonio MA, Ibekwe E, Lucke-Wold B. Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes. JOURNAL OF VASCULAR DISEASES 2023; 2:197-211. [PMID: 37082756 PMCID: PMC10111247 DOI: 10.3390/jvd2020014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate intervention. The etiology varies between cases; however, rupture of an intracranial aneurysm accounts for 80% of medical emergencies. Early intervention and treatment are essential to prevent long-term complications. Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial. The review addresses the current rehabilitative strategies to combat the neurocognitive and behavioral issues that may arise following SAH.
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Affiliation(s)
- Divine C. Nwafor
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA
| | - Brandon D. Kirby
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA
| | - Jacob D. Ralston
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Mark A. Colantonio
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Elochukwu Ibekwe
- Department of Neurology and Neurocritical Care, The Ohio State University, Columbus, OH 43210, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
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17
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Svedung Wettervik T, Lewén A, Enblad P. Fine tuning of neurointensive care in aneurysmal subarachnoid hemorrhage: From one-size-fits-all towards individualized care. World Neurosurg X 2023; 18:100160. [PMID: 36818739 PMCID: PMC9932216 DOI: 10.1016/j.wnsx.2023.100160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/25/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe type of acute brain injury with high mortality and burden of neurological sequelae. General management aims at early aneurysm occlusion to prevent re-bleeding, cerebrospinal fluid drainage in case of increased intracranial pressure and/or acute hydrocephalus, and cerebral blood flow augmentation in case of delayed ischemic neurological deficits. In addition, the brain is vulnerable to physiological insults in the acute phase and neurointensive care (NIC) is important to optimize the cerebral physiology to avoid secondary brain injury. NIC has led to significantly better neurological recovery following aSAH, but there is still great room for further improvements. First, current aSAH NIC management protocols are to some extent extrapolated from those in traumatic brain injury, notwithstanding important disease-specific differences. Second, the same NIC management protocols are applied to all aSAH patients, despite great patient heterogeneity. Third, the main variables of interest, intracranial pressure and cerebral perfusion pressure, may be too superficial to fully detect and treat several important pathomechanisms. Fourth, there is a lack of understanding not only regarding physiological, but also cellular and molecular pathomechanisms and there is a need to better monitor and treat these processes. This narrative review aims to discuss current state-of-the-art NIC of aSAH, knowledge gaps in the field, and future directions towards a more individualized care in the future.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
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18
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Shah AH, Snow R, Wendell LC, Thompson BB, Reznik ME, Furie KL, Mahta A. Association of hemoglobin trend and outcomes in aneurysmal subarachnoid hemorrhage: A single center cohort study. J Clin Neurosci 2023; 107:77-83. [PMID: 36521368 DOI: 10.1016/j.jocn.2022.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/12/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anemia has been linked to delayed cerebral ischemia (DCI) and worse outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the association of hemoglobin (Hb) trend and outcomes is not well studied. We investigated predictors of Hb trend and its association with outcomes in patients with aSAH. Our hypothesis was that a negative Hb trend is associated with poorer outcomes independent of Hb values. METHODS We conducted a retrospective study of a prospectively collected cohort of consecutive patients with aSAH who were admitted to an academic center (2016-2021). We tested the association of Hb trend and values with measures including DCI and poor functional outcome defined as modified Rankin scale 4-6 at 3 months after discharge. Multiple linear regression analysis was used to identify factors associated with Hb difference from admission to discharge. RESULTS We included 310 patients with confirmed aneurysmal etiology (mean age 57 years, SD13.6; 62 % female). Greater Hb decrement from admission to discharge was independently associated with higher likelihood of both DCI (OR 1.28 per 1 g/dl decrease in Hb, 95 % CI 1.08-1.47; p = 0.003) and poor functional outcome (OR 1.27 per 1 g/dl decrease in Hb, 1.03-1.53; p = 0.026) independent of any absolute Hb values. Predictors of Hb decrement from admission to discharge were hospital length of stay, Hunt and Hess grades, female sex and age. CONCLUSION Greater Hb decrement can be associated with higher likelihood of DCI and poor functional outcome in aSAH. More evidence is needed to use Hb trend to guide transfusion threshold in aSAH patients.
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Affiliation(s)
| | - Ryan Snow
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Linda C Wendell
- Division of Neurology, Mount Auburn Hospital, Cambridge, MA, United States
| | - Bradford B Thompson
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Michael E Reznik
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Ali Mahta
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, RI, United States.
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19
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Zhao L, Zhang Y, Lin P, Li W, Huang X, Li H, Xia M, Chen X, Zhu X, Tang X. Postoperative red blood cell distribution width predicts functional outcome in aneurysmal subarachnoid hemorrhage after surgical clipping: A single-center retrospective study. Front Neurol 2022; 13:1036433. [PMID: 36619907 PMCID: PMC9817139 DOI: 10.3389/fneur.2022.1036433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
Objective Red blood cell (RBC) parameters are associated with outcomes following aneurysmal subarachnoid hemorrhage (aSAH), but their predictive value remains uncertain. This study aimed to detect the association between RBC parameters and functional outcome in aSAH patients undergoing surgical clipping. Methods This retrospective observational study included aSAH patients who underwent surgical clipping at Affiliated Hospital of North Sichuan Medical College between August 2016 and September 2019. The functional outcome following aSAH was assessed by modified Rankin Scale (mRS), and mRS 3-6 was defined as poor functional outcome. Results Out of 187 aSAH patients included (62% female, 51-66 years old), 73 patients had poor functional outcome. Multivariate logistic regression of admission parameters showed that World Federation of Neurosurgical Societies (WFNS) grade (odds ratio [95% CI]: 1.322 [1.023-1.707], p = 0.033) and white blood cell (WBC) (odds ratio [95% CI]: 1.136 [1.044-1.236], p = 0.003) were independently associated with poor functional outcome. In postoperative parameters, RBC distribution width (RDW) (odds ratio [95% CI]: 1.411 [1.095-1.818], p = 0.008), mean platelet volume (MPV, odds ratio [95% CI]: 1.253 [1.012-1.552], p = 0.039) and admission WFNS grade (odds ratio [95% CI]: 1.439 [1.119-1.850], p = 0.005) were independently associated with poor functional outcome. The predictive model including WFNS grade, admission WBC, and postoperative RDW and MPV had significantly higher predictive power compared to WFNS grade alone (0.787 [0.722-0.852] vs. 0.707 [0.630-0.784], p = 0.024). The combination of WFNS grade and WBC on admission showed the highest positive predictive value (75.5%) and postoperative RDW and MPV combined with admission WFNS grade and WBC showed the highest negative predictive value (83.7%). Conclusion Postoperative RDW is independently associated with poor functional outcome in aSAH patients undergoing surgical clipping. A combined model containing postoperative RDW may help predict good outcome in patients with aSAH after timely aneurysm clipping.
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Affiliation(s)
- Long Zhao
- Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China,School of Clinical Medicine, North Sichuan Medical College, Nanchong, China,Neurosurgical Research Center, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yi Zhang
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Ping Lin
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Weida Li
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Xingyuan Huang
- School of Psychiatry, North Sichuan Medical College, Nanchong, China
| | - Hangyang Li
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Mingkai Xia
- School of Medical Imaging, North Sichuan Medical College, Nanchong, China
| | - Xinlong Chen
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Xi Zhu
- Outpatient Department, Affiliated Hospital of North Sichuan Medical College, Nanchong, China,*Correspondence: Xi Zhu ✉
| | - Xiaoping Tang
- Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China,Neurosurgical Research Center, Affiliated Hospital of North Sichuan Medical College, Nanchong, China,Xiaoping Tang ✉
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20
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Systematic review and meta-analysis of outcome-relevant anemia in patients with subarachnoid hemorrhage. Sci Rep 2022; 12:20738. [PMID: 36456587 PMCID: PMC9715711 DOI: 10.1038/s41598-022-24591-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/17/2022] [Indexed: 12/02/2022] Open
Abstract
Anemia is a common, treatable condition in patients with aneurysmal subarachnoid hemorrhage (SAH) and has been associated with poor outcome. As there are still no guidelines for anemia management after aneurysm rupture, we aimed to identify outcome-relevant severity of anemia in SAH. We systematically searched PubMed, Embase, Scopus, Web of Science, and Cochrane Library for publications before Oct 23rd, 2022, reporting on anemia in SAH patients. The presence and severity of anemia were assessed according to the reported hemoglobin values and/or institutional thresholds for red blood cells transfusion (RBCT). Out of 1863 original records, 40 full-text articles with a total of 14,701 patients treated between 1996 and 2020 were included in the final analysis (mean 445.48 patients per study). A substantial portion of patients developed anemia during SAH (mean pooled prevalence 40.76%, range 28.3-82.6%). RBCT was administered in a third of the cases (mean 32.07%, range 7.8-88.6%), with institutional threshold varying from 7.00 to 10.00 g/dL (mean 8.5 g/dL). Anemia at the onset of SAH showed no impact on SAH outcome. In contrast, even slight anemia (nadir hemoglobin < 11.0-11.5 g/dL) occurring during SAH was associated with the risk of cerebral infarction and poor outcome at discharge and follow-up. The strongest association with SAH outcome was observed for nadir hemoglobin values ranging between 9.0 and 10.0 g/dL. The effect of anemia on SAH mortality was marginal. The development of anemia during SAH is associated with the risk of cerebral infarction and poor outcome at discharge and follow-up. Outcome-relevant severity of post-SAH anemia begins at hemoglobin levels clearly above the thresholds commonly set for RBCT. Our findings underline the need for further studies to define the optimal management of anemia in SAH patients.
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Said M, Dinger TF, Gümüs M, Rauschenbach L, Chihi M, Rodemerk J, Lenz V, Oppong MD, Uerschels AK, Dammann P, Wrede KH, Sure U, Jabbarli R. Impact of Anemia Severity on the Outcome of an Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2022; 11:jcm11216258. [PMID: 36362486 PMCID: PMC9657573 DOI: 10.3390/jcm11216258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: Previous reports indicate a negative impact of anemia on the outcome of an aneurysmal subarachnoid hemorrhage (SAH). We aimed to identify the outcome-relevant severity of post-SAH anemia. Methods: SAH cases treated at our institution between 01/2005 and 06/2016 were included (n = 640). The onset, duration, and severity (nadir hemoglobin (nHB) level) of anemia during the initial hospital stay were recorded. Study endpoints were new cerebral infarctions, a poor outcome six months post-SAH (modified Rankin scale > 3), and in-hospital mortality. To assess independent associations with the study endpoints, different multivariable regression models were performed, adjusted for relevant patient and baseline SAH characteristics as well as anemia-associated clinical events during the SAH. Results: The rates of anemia were 83.3%, 67.7%, 40.0%, 15.9%, and 4.5% for an nHB < 11 g/dL, < 10 g/dL, < 9 g/dL, < 8 g/dL, and < 7 g/dL, respectively. The higher the anemia severity, the later was the onset (post-SAH days 2, 4, 5.4, 7.6 and 8, p < 0.0001) and the shorter the duration (8 days, 6 days, 4 days, 3 days, and 2 days, p < 0.0001) of anemia. In the final multivariable analysis, only an nHB < 9 g/dL was independently associated with all study endpoints: adjusted odds ratio 1.7/3.22/2.44 for cerebral infarctions/in-hospital mortality/poor outcome. The timing (post-SAH day 3.9 vs. 6, p = 0.001) and duration (3 vs. 5 days, p = 0.041) of anemia with an nHB < 9 g/dL showed inverse associations with the risk of in-hospital mortality, but not with other study endpoints. Conclusions: Anemia is very common in SAH patients affecting four of five individuals during their hospital stay. An nHB decline to < 9 g/dL was strongly associated with all study endpoints, independent of baseline characteristics and SAH-related clinical events. Our data encourage further prospective evaluations of the value of different transfusion strategies in the functional outcomes of SAH patients.
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Affiliation(s)
- Maryam Said
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
- Correspondence: ; Tel.: +49-201-723-1201; Fax: +49-201-723-5909
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Meltem Gümüs
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Jan Rodemerk
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Veronika Lenz
- Institute of Transfusion Medicine, University Hospital of Essen, 45147 Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Anne-Kathrin Uerschels
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Karsten Henning Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg Essen, 47147 Duisburg, Germany
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Salih M, Salem M, Moore J, Thomas AJ, Ogilvy CS. Cost-effectiveness analysis on small (< 5 mm) unruptured intracranial aneurysm follow-up strategies. J Neurosurg 2022; 138:1366-1373. [PMID: 36208436 DOI: 10.3171/2022.8.jns221053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Unruptured intracranial aneurysms are frequently detected during routine clinical diagnostic processes. A significant portion are small aneurysms less than 5 mm in diameter. While follow-up of patients with small aneurysms has been advocated, the cost-effectiveness of such care and the optimal follow-up interval remain unknown. This study aimed to explore the most cost-effective follow-up interval for small (< 5 mm) unruptured intracranial aneurysms.
METHODS
A decision analysis study was performed using a Markov model with Monte Carlo simulations to simulate patients undergoing follow-up by MRA at different time intervals (1-, 2-, 3-, 5-, and 7-year intervals) for small (< 5 mm) unruptured intracranial aneurysms. Input data for the model were extracted from the current literature, primarily meta-analyses. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the model.
RESULTS
Given the current literature and the model in this study, following up every 2 years with noninvasive imaging is the most cost-effective strategy (cost $126,996, effectiveness 21.9 quality-adjusted life-years), showing the highest net monetary benefit. The conclusion remains robust in probabilistic and deterministic sensitivity analyses. As the annual growth risk of small aneurysms and annual rupture risk of growing aneurysms increase, following up every year is optimal. When the cost for follow-up with MRA is less than $2223, following up every year is cost-effective.
CONCLUSIONS
The most cost-effective follow-up strategy for small (< 5 mm) unruptured aneurysms using MRA is following up every 2 years. More frequent follow-up strategies or prompt preventive treatment would be more appropriate in patients with higher risk factors for growth and aneurysm rupture.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Mohamed Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Justin Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Ajith J. Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Christopher S. Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
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Solhpour A, Kumar S, Koch MJ, Doré S. Impact of blood component transfusions, tranexamic acid and fluids on subarachnoid hemorrhage outcomes. BRAIN HEMORRHAGES 2022. [DOI: 10.1016/j.hest.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA.
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
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25
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Admission Serum Iron as an Independent Risk Factor for Postoperative Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage: A Propensity-Matched Analysis. Brain Sci 2022; 12:brainsci12091183. [PMID: 36138920 PMCID: PMC9496804 DOI: 10.3390/brainsci12091183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/12/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023] Open
Abstract
This study aimed to investigate the association between serum iron (SI) and postoperative delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH). We retrospectively analyzed 985 consecutive adult patients diagnosed with aSAH. Demographic, clinical, and laboratory data were recorded. Univariate and multivariate analyses were employed to assess the association between SI and DCI. Propensity-score matching (PSM) analysis was implemented to reduce confounding. Postoperative DCI developed in 14.38% of patients. Lower SI upon admission was detected in aSAH patients with severe clinical conditions and severe aSAH. SI was negatively correlated with WFNS grade (r = −0.3744, p < 0.001) and modified Fisher (mFisher) grade (r = −0.2520, p < 0.001). Multivariable analysis revealed lower SI was independently associated with DCI [odds ratios (OR) 0.281, 95% confidence interval (CI) 0.177−0.448, p < 0.001], while WFNS grade and mFisher grade were not. The receiver-operating characteristics (ROC) curve analysis of SI for DCI gave an area under the curve (AUC) of 0.7 and an optimal cut-off of 7.5 μmol/L (95% CI 0.665 to 0.733, p < 0.0001). PSM demonstrated the DCI group had a significantly lower SI than the non-DCI group (10.91 ± 6.86 vs. 20.34 ± 8.01 μmol/L, p < 0.001). Lower SI remained a significant independent predictor for DCI and an independent poor prognostic factor of aSAH in multivariate analysis (OR 0.363, 95% CI 0.209−0.630, p < 0.001). The predictive performance of SI for poor outcome had a corresponding AUC of 0.718 after PSM. Lower SI upon admission is significantly associated with WFNS grade, mFisher grade, and predicts postoperative DCI and poor outcome at 90 days following aSAH.
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Matin N, Sarhadi K, Crooks CP, Lele AV, Srinivasan V, Johnson NJ, Robba C, Town JA, Wahlster S. Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80-120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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Affiliation(s)
- Nassim Matin
- Department of Neurology, University of Washington, Seattle, WA USA
| | - Kasra Sarhadi
- Department of Neurology, University of Washington, Seattle, WA USA
| | | | - Abhijit V. Lele
- Department of Anesthesiology, University of Washington, Seattle, WA USA
- Department of Neurological Surgery, University of Washington, Seattle, WA USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington, Seattle, WA USA
| | - Nicholas J. Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA USA
| | - Chiara Robba
- Departments of Anesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), Genoa, Italy
| | - James A. Town
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, WA USA
- Department of Anesthesiology, University of Washington, Seattle, WA USA
- Department of Neurological Surgery, University of Washington, Seattle, WA USA
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The effect of sex differences on complications and 90-day outcomes after aneurysmal subarachnoid hemorrhage: a propensity score-matched analysis. Neurosurg Rev 2022; 45:3339-3347. [DOI: 10.1007/s10143-022-01836-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/28/2022] [Accepted: 07/14/2022] [Indexed: 12/21/2022]
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Schoenes B, Schrezenmeier H, Welte M. [Rational therapy with erythrocyte concentrates - Update 2022]. Dtsch Med Wochenschr 2022; 147:780-796. [PMID: 35672025 DOI: 10.1055/a-1716-8148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The use of red blood cell concentrates must follow the dictates of a rational indication. To further ensure this, the "Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives" 1 of the German Medical Association, published in 2009 and last revised in part in 2014, were systematically revised in 2020. This article presents them.
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Li R, Lin F, Chen Y, Lu J, Han H, Ma L, Zhao Y, Yan D, Li R, Yang J, He S, Li Z, Zhang H, Yuan K, Wang K, Hao Q, Ye X, Wang H, Li H, Zhang L, Shi G, Zhou J, Zhao Y, Zhang Y, Li Y, Wang S, Chen X, Zhao Y. Elevated blood hemoglobin on admission as an independent predictor of unfavorable outcomes in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2022; 45:2689-2699. [DOI: 10.1007/s10143-022-01780-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/18/2022] [Accepted: 03/28/2022] [Indexed: 11/28/2022]
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Lessons Learned from Phase II and Phase III Trials Investigating Therapeutic Agents for Cerebral Ischemia Associated with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:662-681. [PMID: 34940927 DOI: 10.1007/s12028-021-01372-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022]
Abstract
One of the challenges in bringing new therapeutic agents (since nimodipine) in for the treatment of cerebral ischemia associated with aneurysmal subarachnoid hemorrhage (aSAH) is the incongruence in therapeutic benefit observed between phase II and subsequent phase III clinical trials. Therefore, identifying areas for improvement in the methodology and interpretation of results is necessary to increase the value of phase II trials. We performed a systematic review of phase II trials that continued into phase III trials, evaluating a therapeutic agent for the treatment of cerebral ischemia associated with aSAH. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews, and review was based on a peer-reviewed protocol (International Prospective Register of Systematic Reviews no. 222965). A total of nine phase III trials involving 7,088 patients were performed based on eight phase II trials involving 1558 patients. The following therapeutic agents were evaluated in the selected phase II and phase III trials: intravenous tirilazad, intravenous nicardipine, intravenous clazosentan, intravenous magnesium, oral statins, and intraventricular nimodipine. Shortcomings in several design elements of the phase II aSAH trials were identified that may explain the incongruence between phase II and phase III trial results. We suggest the consideration of the following strategies to improve phase II design: increased focus on the selection of surrogate markers of efficacy, selection of the optimal dose and timing of intervention, adjustment for exaggerated estimate of treatment effect in sample size calculations, use of prespecified go/no-go criteria using futility design, use of multicenter design, enrichment of the study population, use of concurrent control or placebo group, and use of innovative trial designs such as seamless phase II to III design. Modifying the design of phase II trials on the basis of lessons learned from previous phase II and phase III trial combinations is necessary to plan more effective phase III trials.
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Abstract
PURPOSE OF THE REVIEW Anemia has been called the fifth cardiovascular risk factor. It is one of the most prevalent pathologies worldwide. In this article, we aimed to perform a narrative review of the main cerebrovascular complications of anemia and its influence on stroke prognosis. RECENT FINDINGS Both hypoproliferative anemia (thalassemia, iron deficiency anemia, etc.) and hyperproliferative anemia (sickle cell disease, paroxysmal nocturnal hemoglobinuria, hereditary spherocytosis, etc.) are associated to cerebrovascular disease ranging from transient ischemic attack to ischemic stroke and hemorrhagic stroke with both intraparenchymal hemorrhage and subarachnoid hemorrhage or cerebral venous thrombosis. Anemia is associated to a worse prognosis in patients with cerebrovascular disease In some cases, like sickle cell disease, pathophysiological mechanisms and therapeutic guidelines are well established, while in others, due to their rarity, there are still lack of robust data. More studies are needed to clarify how the prognosis of stroke patients with anemia could be improved.
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32
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Xie Y, Wang Y, Zhou Y, Liu M, Li S, Bao Y, Jiang W, Tang S, Li F, Xue H, Li L, Gong X, Liu Y, Wang W, Li T. A Nomogram for Predicting Acute Respiratory Failure After Cervical Traumatic Spinal Cord Injury Based on Admission Clinical Findings. Neurocrit Care 2021; 36:421-433. [PMID: 34346037 PMCID: PMC8964578 DOI: 10.1007/s12028-021-01302-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/14/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Acute respiratory failure (ARF) is a common medical complication in patients with cervical traumatic spinal cord injury (TSCI). To identify independent predictors for ARF onset in patients who underwent cervical TSCI without premorbid respiratory diseases and to apply appropriate medical supports based on accurate prediction, a nomogram relating admission clinical information was developed for predicting ARF during acute care period. METHODS We retrospectively reviewed clinical profiles of patients who suffered cervical TSCI and were emergently admitted to Qingdao Municipal Hospital from 2014 to 2020 as the training cohort. Univariate analysis was performed using admission clinical variables to estimate associated factors and a nomogram for predicting ARF occurrence was generated based on the independent predictors from multivariate logistic regression analysis. This nomogram was assessed by concordance index for discrimination and calibration curve with internal-validated bootstrap strategy. Receiver operating characteristic curve was conducted to compare the predictive accuracy between the nomogram and the traditional gold standard, which combines neuroimaging and neurological measurements by using area under the receiver operating characteristic curve (AUC). An additional 56-patient cohort from another medical center was retrospectively reviewed as the test cohort for external validation of the nomogram. RESULTS 162 patients were eligible for this study and were included in the training cohort, among which 25 individuals developed ARF and were recorded to endure more complications. Despite the aggressive treatments and prolonged intensive care unit cares, 14 patients insulted with ARF died. Injury level, American Spinal Injury Association Impairment Scale (AIS) grade, admission hemoglobin (Hb), platelet to lymphocyte ratio, and neutrophil percentage to albumin ratio (NPAR) were independently associated with ARF onset. The concordance index of the nomogram incorporating these predictors was 0.933 in the training cohort and 0.955 in the test cohort, although both calibrations were good. The AUC of the nomogram was equal to concordance index, which presented better predictive accuracy compared with previous measurements using neuroimaging and AIS grade (AUC 0.933 versus 0.821, Delong's test p < 0.001). Similar significant results were also found in the test cohort (AUC 0.955 versus 0.765, Delong's test p = 0.034). In addition, this nomogram was translated to a Web-based calculator that could generate individual probability for ARF in a visualized form. CONCLUSIONS The nomogram incorporating the injury level, AIS grade, admission Hb, platelet to lymphocyte ratio, and NPAR is a promising model to predict ARF in patients with cervical TSCI who are absent from previous respiratory dysfunction. This nomogram can be offered to clinicians to stratify patients, strengthen evidence-based decision-making, and apply appropriate individualized treatment in the field of acute clinical care.
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Affiliation(s)
- Yongfan Xie
- Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), No. 1 Jiaozhou Road, Qingdao, 266011, Shandong, People's Republic of China.,School of Medicine, Qingdao University, No. 308 Ningxia Road, Qingdao, 266011, Shandong, People's Republic of China
| | - Yongyi Wang
- Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), No. 1 Jiaozhou Road, Qingdao, 266011, Shandong, People's Republic of China.,School of Medicine, Qingdao University, No. 308 Ningxia Road, Qingdao, 266011, Shandong, People's Republic of China
| | - Yong Zhou
- Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), No. 1 Jiaozhou Road, Qingdao, 266011, Shandong, People's Republic of China
| | - Mingxing Liu
- Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), No. 1 Jiaozhou Road, Qingdao, 266011, Shandong, People's Republic of China
| | - Shengli Li
- Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), No. 1 Jiaozhou Road, Qingdao, 266011, Shandong, People's Republic of China
| | - Yue Bao
- Department of Neurosurgery, Qingdao Municipal Hospital, No. 5 Donghai Zhong Road, Qingdao, 266071, Shandong, People's Republic of China.,Department of Neurosurgery, Neuro Intensive Care Unit, Qingdao Municipal Hospital, No. 5 Donghai Zhong Road, Qingdao, 266071, Shandong, People's Republic of China
| | - Wenbo Jiang
- Department of Neurosurgery, Qingdao Municipal Hospital, No. 5 Donghai Zhong Road, Qingdao, 266071, Shandong, People's Republic of China.,Department of Neurosurgery, Neuro Intensive Care Unit, Qingdao Municipal Hospital, No. 5 Donghai Zhong Road, Qingdao, 266071, Shandong, People's Republic of China
| | - Siwei Tang
- Department of Neurosurgery, Neuro Intensive Care Unit, Qingdao Municipal Hospital, No. 5 Donghai Zhong Road, Qingdao, 266071, Shandong, People's Republic of China
| | - Fangbao Li
- Department of Neurosurgery, Qingdao Municipal Hospital, No. 5 Donghai Zhong Road, Qingdao, 266071, Shandong, People's Republic of China
| | - Hao Xue
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, No.107 Wenhua Xi Road, Jinan, Shandong, People's Republic of China
| | - Luo Li
- School of Medicine, Qingdao University, No. 308 Ningxia Road, Qingdao, 266011, Shandong, People's Republic of China.,Department of Neurosurgery, Qingdao Municipal Hospital, No. 5 Donghai Zhong Road, Qingdao, 266071, Shandong, People's Republic of China
| | - Xingyuan Gong
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, People's Republic of China
| | - Yongliang Liu
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, People's Republic of China.
| | - Weimin Wang
- Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), No. 1 Jiaozhou Road, Qingdao, 266011, Shandong, People's Republic of China. .,School of Medicine, Qingdao University, No. 308 Ningxia Road, Qingdao, 266011, Shandong, People's Republic of China.
| | - Tong Li
- Department of Neurosurgery, Qingdao Municipal Hospital, No. 5 Donghai Zhong Road, Qingdao, 266071, Shandong, People's Republic of China. .,Department of Neurosurgery, Neuro Intensive Care Unit, Qingdao Municipal Hospital, No. 5 Donghai Zhong Road, Qingdao, 266071, Shandong, People's Republic of China.
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Hu Y, Chen W, Li C, Wang X, Luo J, Cheng B. LncRNA ANRIL Facilitates Vascular Smooth Muscle Cell Proliferation and Suppresses Apoptosis via Modulation of miR-7/FGF2 Pathway in Intracranial Aneurysms. Neurocrit Care 2021; 36:106-115. [PMID: 34286462 DOI: 10.1007/s12028-021-01262-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/20/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Proliferation and apoptosis of vascular smooth muscle cells (VSMCs) are linked to intracranial aneurysm (IA) formation and progression. Long antisense noncoding RNA in the INK4 locus (ANRIL) has been reported to regulate VSMC functions in several cardiovascular diseases. However, little is known about how ANRIL influences VSMC proliferation and apoptosis during IA pathogenesis. METHODS The expression level of ANRIL in the plasma and arterial wall tissues of patients with IA was detected by real-time quantitative polymerase chain reaction. The functional role of ANRIL in the regulation of VSMC proliferation and apoptosis and its downstream regulatory mechanism were determined using Cell Counting Kit 8, immunofluorescence, terminal-deoxynucleotidyl transferase-mediated UTP nick end labeling, western blotting, luciferase reporter assay, and RNA immunoprecipitation assay. RESULTS ANRIL was downregulated in the plasma and arterial wall tissues of patients with IA, when compared with control groups. Overexpression of ANRIL significantly promoted VSMC proliferation and blocked cell apoptosis. Mechanistic studies demonstrated that ANRIL directly bound to microRNA-7 (miR-7) and that overexpression of miR-7 overturned the increased cell proliferation and decreased cell apoptosis, which was induced by ANRIL restoration. Besides, further study showed that ANRIL positively regulated fibroblast growth factor 2 (FGF2) expression via targeting miR-7. CONCLUSIONS These results suggested that ANRIL affects VSMC proliferation and apoptosis via regulation of the miR-7/FGF2 pathway in IA, which provided a potential novel strategy for the treatment of IA.
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Affiliation(s)
- Yangchun Hu
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China.
| | - Weiwei Chen
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
| | - Chao Li
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
| | - Xiaojian Wang
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
| | - Jing Luo
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
| | - Baochun Cheng
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, China
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Oka F, Sadeghian H, Yaseen MA, Fu B, Kura S, Qin T, Sakadžić S, Sugimoto K, Inoue T, Ishihara H, Nomura S, Suzuki M, Ayata C. Intracranial pressure spikes trigger spreading depolarizations. Brain 2021; 145:194-207. [PMID: 34245240 PMCID: PMC9126007 DOI: 10.1093/brain/awab256] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/29/2021] [Accepted: 06/17/2021] [Indexed: 01/09/2023] Open
Abstract
Spreading depolarizations are highly prevalent and spatiotemporally punctuated events worsening the outcome of brain injury. Trigger factors are poorly understood but may be linked to sudden worsening in supply-demand mismatch in compromised tissue. Sustained or transient elevations in intracranial pressure are also prevalent in the injured brain. Here, using a mouse model of large hemispheric ischaemic stroke, we show that mild and brief intracranial pressure elevations (20 or 30 mmHg for just 3 min) potently trigger spreading depolarizations in ischaemic penumbra (4-fold increase in spreading depolarization occurrence). We also show that 30 mmHg intracranial pressure spikes as brief as 30 s are equally effective. In contrast, sustained intracranial pressure elevations to the same level for 30 min do not significantly increase the spreading depolarization rate, suggesting that an abrupt disturbance in the steady state equilibrium is required to trigger a spreading depolarization. Laser speckle flowmetry consistently showed a reduction in tissue perfusion, and two-photon pO2 microscopy revealed a drop in venous pO2 during the intracranial pressure spikes suggesting increased oxygen extraction fraction, and therefore, worsening supply-demand mismatch. These haemodynamic changes during intracranial pressure spikes were associated with highly reproducible increases in extracellular potassium levels in penumbra. Consistent with the experimental data, a higher rate of intracranial pressure spikes was associated with spreading depolarization clusters in a retrospective series of patients with aneurysmal subarachnoid haemorrhage with strong temporal correspondence. Altogether, our data show that intracranial pressure spikes, even when mild and brief, are capable of triggering spreading depolarizations. Aggressive prevention of intracranial pressure spikes may help reduce spreading depolarization occurrence and improve outcomes after brain injury.
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Affiliation(s)
- Fumiaki Oka
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA,Department of Neurosurgery, Yamaguchi Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan,Correspondence to: Fumiaki Oka, MD, PhD Department of Neurosurgery, Yamaguchi Graduate School of Medicine 1-1-1, Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan E-mail:
| | - Homa Sadeghian
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Mohammad A Yaseen
- Optics Division, MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Buyin Fu
- Optics Division, MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Sreekanth Kura
- Optics Division, MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Tao Qin
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Sava Sakadžić
- Optics Division, MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Kazutaka Sugimoto
- Department of Neurosurgery, Yamaguchi Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
| | - Takao Inoue
- Department of Advanced ThermoNeuroBiology, Yamaguchi Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery, Yamaguchi Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
| | - Sadahiro Nomura
- Department of Neurosurgery, Yamaguchi Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
| | - Michiyasu Suzuki
- Department of Advanced ThermoNeuroBiology, Yamaguchi Graduate School of Medicine, Ube, Yamaguchi, 755-8505, Japan
| | - Cenk Ayata
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA,Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA,Correspondence may also be addressed to: Cenk Ayata, MD, PhD Massachusetts General Hospital, 149 13th street, Room 6408, Charlestown, MA 02129, USA E-mail:
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Castella A, Attanasio L, Schuind S, Peluso L, Annoni F, Vincent JL, Creteur J, Taccone FS, Gouvêa Bogossian E. Association of anemia and transfusions with outcome after subarachnoid hemorrhage. Clin Neurol Neurosurg 2021; 206:106676. [PMID: 34010752 DOI: 10.1016/j.clineuro.2021.106676] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The benefits of correcting anemia using red blood cell transfusion (RBCT) after subarachnoid hemorrhage (SAH) are controversial. We aimed to evaluate the role of anemia and RBCT on neurological outcome after SAH using a restrictive transfusion policy. OBJECTIVE We reviewed our institutional database of adult patients admitted to the Department of Intensive Care (ICU) after non-traumatic SAH over a 5-year period. We recorded hemoglobin (Hb) levels daily for a maximum of 20 days, as well as the use of RBCT. Unfavorable neurological outcome (UO) was defined as a Glasgow Outcome Score of 1-3 at 3 months. RESULTS Among 270 eligible patients, UO was observed in 40% of them. Patients with UO had lower Hb over time and received RBCT more frequently than others (15/109, 14% vs. 6/161, 4% - p < 0.01). Pre-RBCT median Hb values were similar in UO and FO patients (6.9 [6.6-7.1] vs. 7.3 [6.3-8.1] g/dL - p = 0.21). The optimal discriminative Hb threshold for UO was 9 g/dL. In a multivariable analysis, neither anemia nor RBCT were independently associated with UO. CONCLUSION In this retrospective single center study using a restrictive strategy of RBCT in SAH patients was not associated with worse outcome in 3 months.
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Affiliation(s)
- Alberto Castella
- Department of Intensive Care, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Laila Attanasio
- Department of Intensive Care, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium.
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Schoenes B, Schrezenmeier H, Welte M. Rationale Therapie mit Erythrozytenkonzentraten – Update 2020. TRANSFUSIONSMEDIZIN 2021. [DOI: 10.1055/a-1256-4487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
ZusammenfassungDer Einsatz von Erythrozytenkonzentraten muss dem Gebot einer rationalen Indikation folgen. Um dies weiter zu gewährleisten, wurden die 2009 publizierten und zuletzt 2014 in Teilen revidierten „Querschnitts-Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten“ 1 der Bundesärztekammer 2020 einer systematischen Novellierung unterzogen. Der Artikel stellt sie vor.
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Chen P, Wang Y, Zhang XH, Kang DZ, Lin XZ, Lin QS. The Use of Acute Normovolemic Hemodilution in Clipping Surgery for Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 148:e209-e217. [PMID: 33385596 DOI: 10.1016/j.wneu.2020.12.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The occurrence of coronavirus disease 2019 (COVID-19) has overwhelmed the blood supply chain worldwide and severely influenced clinical procedures with potential massive blood loss, such as clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH). Whether acute normovolemic hemodilution (ANH) is safe and effective in aneurysm clipping remains largely unknown. METHODS Patients with aSAH who underwent clipping surgery within 72 hours from bleeding were included. The patients in the ANH group received 400 mL autologous blood collection, and the blood was returned as needed during surgery. The relationships between ANH and perioperative allogeneic blood transfusion, postoperative outcome, and complications were analyzed. RESULTS Sixty-two patients with aSAH were included between December 2019 and June 2020 (20 in the ANH group and 42 in the non-ANH group). ANH did not reduce the need of perioperative blood transfusion (3 [15%] vs. 5 [11.9%]; P = 0.734). However, ANH significantly increased serum hemoglobin levels on postoperative day 1 (11.5 ± 2.5 g/dL vs. 10.3 ± 2.0 g/dL; P = 0.045) and day 3 (12.1 ± 2.0 g/dL vs. 10.7 ± 1.3 g/dL; P = 0.002). Multivariable analysis indicated that serum hemoglobin level on postoperative day 1 (odds ratio, 0.895; 95% confidence interval, 0.822-0.973; P = 0.010) was an independent risk factor for unfavorable outcome, and receiver operating characteristic curve analysis showed that it had a comparable predictive power to World Federation of Neurosurgical Societies grade (Z = 0.275; P > 0.05). CONCLUSIONS ANH significantly increased postoperative hemoglobin levels, and it may hold the potential to improve patients' outcomes. Routine use of ANH should be considered in aneurysm clipping surgery.
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Affiliation(s)
- Ping Chen
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Ying Wang
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Xin-Huang Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - De-Zhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Fujian Neuro-Medicine Center, Fuzhou, Fujian, China; Key Clinical Specialty Construction of Fujian, Fuzhou, Fujian, China
| | - Xian-Zhong Lin
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Qing-Song Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Fujian Neuro-Medicine Center, Fuzhou, Fujian, China; Key Clinical Specialty Construction of Fujian, Fuzhou, Fujian, China.
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38
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Chu C, Xu G, Li X, Duan Z, Tao L, Cai H, Yang M, Zhang X, Chen B, Zheng Y, Shi H, Li X. Sustained expression of MCP-1 induced low wall shear stress loading in conjunction with turbulent flow on endothelial cells of intracranial aneurysm. J Cell Mol Med 2020; 25:110-119. [PMID: 33332775 PMCID: PMC7810920 DOI: 10.1111/jcmm.15868] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/30/2020] [Accepted: 08/24/2020] [Indexed: 12/28/2022] Open
Abstract
Shear stress was reported to regulate the expression of AC007362, but its underlying mechanisms remain to be explored. In this study, to isolate endothelial cells of blood vessels, unruptured and ruptured intracranial aneurysm (IA) tissues were collected from IA patients. Subsequently, quantitative real‐time PCR (qRT‐PCR), Western blot and luciferase assay were performed to investigate the relationships between AC007362, miRNAs‐493 and monocyte chemoattractant protein‐1 (MCP‐1) in human umbilical vein endothelial cells (HUVECs) exposed to shear stress. Reduced representation bisulphite sequencing (RRBS) was performed to assess the level of DNA methylation in AC007362 promoter. Accordingly, AC007362 and MCP‐1 were significantly up‐regulated while miR‐493 was significantly down‐regulated in HUVECs exposed to shear stress. AC007362 could suppress the miR‐493 expression and elevate the MCP‐1 expression, and miR‐493 was shown to respectively target AC007362 and MCP‐1. Moreover, shear stress in HUVECs led to the down‐regulated DNA methyltransferase 1 (DNMT1), as well as the decreased DNA methylation level of AC007362 promoter. Similar results were also observed in ruptured IA tissues when compared with unruptured IA tissues. In conclusion, this study presented a deep insight into the operation of the regulatory network of AC007362, miR‐493 and MCP‐1 upon shear stress. Under shear stress, the expression of AC007362 was enhanced by the inhibited promoter DNA methylation, while the expression of MCP‐1 was enhanced by sponging the expression of miR‐493.
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Affiliation(s)
- Cheng Chu
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Gang Xu
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Xiaocong Li
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Zuowei Duan
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Lihong Tao
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Hongxia Cai
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Ming Yang
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Xinjiang Zhang
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Bin Chen
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Yanyu Zheng
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Hongcan Shi
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Xiaoyu Li
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
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Neifert SN, Chapman EK, Martini ML, Shuman WH, Schupper AJ, Oermann EK, Mocco J, Macdonald RL. Aneurysmal Subarachnoid Hemorrhage: the Last Decade. Transl Stroke Res 2020; 12:428-446. [PMID: 33078345 DOI: 10.1007/s12975-020-00867-0] [Citation(s) in RCA: 173] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Emily K Chapman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Michael L Martini
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - William H Shuman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | | | - Eric K Oermann
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - R Loch Macdonald
- University Neurosciences Institutes, University of California San Francisco, Fresno Campus, Fresno, CA, 93701-2302, USA.
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40
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Schupper AJ, Eagles ME, Neifert SN, Mocco J, Macdonald RL. Lessons from the CONSCIOUS-1 Study. J Clin Med 2020; 9:jcm9092970. [PMID: 32937959 PMCID: PMC7564635 DOI: 10.3390/jcm9092970] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/02/2020] [Accepted: 09/09/2020] [Indexed: 12/25/2022] Open
Abstract
After years of research on treatment of aneurysmal subarachnoid hemorrhage (aSAH), including randomized clinical trials, few treatments have been shown to be efficacious. Nevertheless, reductions in morbidity and mortality have occurred over the last decades. Reasons for the improved outcomes remain unclear. One randomized clinical trial that has been examined in detail with these questions in mind is Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1). This was a phase-2 trial testing the effect of clazosentan on angiographic vasospasm (aVSP) in patients with aSAH. Clazosentan decreased moderate to severe aVSP. There was no statistically significant effect on the extended Glasgow outcome score (GOS), although the study was not powered for this endpoint. Data from the approximately 400 patients in the study were detailed, rigorously collected and documented and were generously made available to one investigator. Post-hoc analyses were conducted which have expanded our knowledge of the management of aSAH. We review those analyses here.
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Affiliation(s)
- Alexander J. Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - Matthew E. Eagles
- Department of Clinical Neurosciences, Division of Neurosurgery, Alberta Children’s Hospital, University of Calgary, Alberta, AB T3B 6A8, Canada;
| | - Sean N. Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - R. Loch Macdonald
- Department of Neurological Surgery, UCSF Fresno, Fresno, CA 93701, USA
- Correspondence: ; Tel.: +1 (559) 459-3705
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41
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Du K, Cheng X, Zhang W. The importance of hospital length of stay in patients with acute brain injury. J Crit Care 2020; 58:127. [DOI: 10.1016/j.jcrc.2019.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/05/2019] [Indexed: 11/28/2022]
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Early Hemoglobin Status as a Predictor of Long-Term Mortality for Sepsis Patients in Intensive Care Units. Shock 2020; 55:215-223. [PMID: 33433167 DOI: 10.1097/shk.0000000000001612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES It is still not clear what influences hemoglobin has on the outcomes of patients with sepsis. The intention of this research is to investigate the impact of early hemoglobin levels on clinical outcomes for sepsis. METHODS In this single-center, cohort study, each patient was put into one of four groups dependent on hemoglobin levels of 70 g/L, 80 g/L, or 90 g/L in the first 48 h of being admitted to intensive care unit (ICU). Adjustments for baseline/confounding factors were made using the multiple Cox regression model. RESULTS In all, 235 septic patients were examined in this research. The non-survivors exhibited significantly higher levels for early hemoglobin status at or below 80 g/L (33.7% vs. 19.4%, P = 0.016) than survivors. Survival curve demonstrated that septic patients with early hemoglobin levels at or below 80 g/L survived at significantly lower rates than those with hemoglobin above 80 g/L. Multivariate Cox analysis demonstrated that levels of 1-year mortality rose as early hemoglobin levels fell in the first 48 h after ICU admission, with relative risks for 80 g/L to 90 g/L, 70 g/L to 80 g/L, and at or below 70 g/L being respectively 1.11 (95% CI: 0.654-1.882), 1.742 (95% CI: 0.969-3.133), 1.981 (95% CI: 1.124-3.492) times higher than those for hemoglobin levels above 90 g/L. CONCLUSIONS Hemoglobin levels at or below 80 g/L in the first 48 h after ICU admission are an alternative indicator for predicting long-term mortality of sepsis. Awareness should be encouraged of the importance of targeting early hemoglobin levels when treating sepsis to improve prognosis.
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Altersberger VL, Kellert L, Al Sultan AS, Martinez-Majander N, Hametner C, Eskandari A, Heldner MR, van den Berg SA, Zini A, Padjen V, Kägi G, Pezzini A, Polymeris A, DeMarchis GM, Tiainen M, Räty S, Nannoni S, Jung S, Zonneveld TP, Maffei S, Bonati L, Lyrer P, Sibolt G, Ringleb PA, Arnold M, Michel P, Curtze S, Nederkoorn PJ, Engelter ST, Gensicke H. Effect of haemoglobin levels on outcome in intravenous thrombolysis-treated stroke patients. Eur Stroke J 2020; 5:138-147. [PMID: 32637647 PMCID: PMC7313367 DOI: 10.1177/2396987319889468] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/21/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Alterations in haemoglobin levels are frequent in stroke patients. The prognostic meaning of anaemia and polyglobulia on outcomes in patients treated with intravenous thrombolysis is ambiguous. PATIENTS AND METHODS In this prospective multicentre, intravenous thrombolysis register-based study, we compared haemoglobin levels on hospital admission with three-month poor outcome (modified Rankin Scale 3-6), mortality and symptomatic intracranial haemorrhage (European Cooperative Acute Stroke Study II-criteria (ECASS-II-criteria)). Haemoglobin level was used as continuous and categorical variable distinguishing anaemia (female: <12 g/dl; male: <13 g/dl) and polyglobulia (female: >15.5 g/dl; male: >17 g/dl). Anaemia was subdivided into mild and moderate/severe (female/male: <11 g/dl). Normal haemoglobin level (female: 12.0-15.5 g/dl, male: 13.0-17.0 g/dl) served as reference group. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated with logistic regression models. RESULTS Among 6866 intravenous thrombolysis-treated stroke patients, 5448 (79.3%) had normal haemoglobin level, 1232 (17.9%) anaemia - of those 903 (13.2%) had mild and 329 (4.8%) moderate/severe anaemia - and 186 (2.7%) polyglobulia. Anaemia was associated with poor outcome (ORadjusted 1.25 (1.05-1.48)) and mortality (ORadjusted 1.58 (1.27-1.95)). In anaemia subgroups, both mild and moderate/severe anaemia independently predicted poor outcome (ORadjusted 1.29 (1.07-1.55) and 1.48 (1.09-2.02)) and mortality (ORadjusted 1.45 (1.15-1.84) and ORadjusted 2.00 (1.46-2.75)). Each haemoglobin level decrease by 1 g/dl independently increased the risk of poor outcome (ORadjusted 1.07 (1.02-1.11)) and mortality (ORadjusted 1.08 (1.02-1.15)). Anaemia was not associated with occurrence of symptomatic intracranial haemorrhage. Polyglobulia did not change any outcome. DISCUSSION The more severe the anaemia, the higher the probability of poor outcome and death. Severe anaemia might be a target for interventions in hyperacute stroke. CONCLUSION Anaemia on admission, but not polyglobulia, is a strong and independent predictor of poor outcome and mortality in intravenous thrombolysis-treated stroke patients.
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Affiliation(s)
- Valerian L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lars Kellert
- Department of Neurology, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ashraf Eskandari
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Sophie A van den Berg
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrea Zini
- Stroke Unit, Department of Neuroscience, Ospedale Civile S. Agostino-Estense, Modena University Hospital, Modena, Italy
| | - Visnja Padjen
- Neurology Clinic, Clinical Centre of Serbia, Beograd, Serbia
| | - Georg Kägi
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Alexandros Polymeris
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian M DeMarchis
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marjaana Tiainen
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Silja Räty
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Stefania Nannoni
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Thomas P Zonneveld
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Stefania Maffei
- Stroke Unit, Department of Neuroscience, Ospedale Civile S. Agostino-Estense, Modena University Hospital, Modena, Italy
| | - Leo Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gerli Sibolt
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - for the Thrombolysis in Stroke Patients (TRISP) collaborators
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Stroke Unit, Department of Neuroscience, Ospedale Civile S. Agostino-Estense, Modena University Hospital, Modena, Italy
- Neurology Clinic, Clinical Centre of Serbia, Beograd, Serbia
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
- Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
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Mikhail M, Ayling OGS, Eagles ME, Ibrahim GM, Macdonald RL. Association between weekend admissions and mortality after aneurysmal subarachnoid hemorrhage: the "weekend effect" revisited. J Neurosurg 2020; 132:1167-1173. [PMID: 30925472 DOI: 10.3171/2019.1.jns183185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 01/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Higher mortality has been reported with weekend or after-hours patient admission across a wide range of surgical and medical specialties, a phenomenon termed the "weekend effect." The authors evaluated whether weekend admission contributed to death and long-term neurological outcome in patients following aneurysmal subarachnoid hemorrhage. METHODS A post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) study was conducted. Univariable and stepwise multivariable logistic regression analyses were performed to assess the associations between weekend admission and mortality and long-term neurological outcome. RESULTS Of 413 subjects included in the CONSCIOUS-1 study, 140 patients had been admitted during the weekend. A significant interaction was identified between weekend admission and neurological grade on presentation, suggesting that the outcomes of patients who had initially presented with a poor grade were disproportionately influenced by the weekend admission. On stepwise multivariable logistic regression in the subgroup of patients who had presented with a poor neurological grade (29 of 100 patients), admission on the weekend was found to be independently associated with death (OR 6.59, 95% CI 1.62-26.88, p = 0.009). Weekend admission was not associated with long-term neurological outcome. CONCLUSIONS Weekend admission was an independent risk factor for death within 12 weeks following aneurysmal subarachnoid hemorrhage in patients presenting with a poor neurological grade. Further work is required to identify and mitigate any mediating factors.
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Affiliation(s)
| | - Oliver G S Ayling
- 2Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia
| | | | - George M Ibrahim
- 4Division of Neurosurgery, Department of Surgery, Hospital for Sick Children, University of Toronto, Ontario
| | - R Loch Macdonald
- 5Division of Neurosurgery, St. Michael's Hospital
- 6Labatt Family Centre of Excellence in Brain Injury and Trauma Research
- 7Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital; and
- 8Departments of Physiology and Surgery, University of Toronto, Ontario, Canada
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45
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Maher M, Schweizer TA, Macdonald RL. Treatment of Spontaneous Subarachnoid Hemorrhage: Guidelines and Gaps. Stroke 2020; 51:1326-1332. [PMID: 31964292 DOI: 10.1161/strokeaha.119.025997] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Tom A Schweizer
- Neuroscience Research Program, Li Ka Shing Knowledge Institute, Institute of Medical Science (T.A.S.)
| | - R Loch Macdonald
- Division of Neurosurgery, Departments of Surgery and Physiology, Keenan Research Centre for Biomedical Science, St Michael's Hospital, University of Toronto, Ontario, Canada (R.L.M.)
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