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Miao G, Cai Z, He X, Yang J, Zhang Y, Ma A, Zhao X, Tan M. Development of a predictive nomogram for 28-day mortality risk in non-traumatic or post-traumatic subarachnoid hemorrhage patients. Neurol Sci 2024; 45:2149-2163. [PMID: 37994964 DOI: 10.1007/s10072-023-07199-5] [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: 06/07/2023] [Accepted: 11/08/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE Subarachnoid hemorrhage (SAH) is associated with high rates of mortality and permanent disability. At present, there are few definite clinical tools to predict prognosis in SAH patients. The current study aims to develop and assess a predictive nomogram model for estimating the 28-day mortality risk in both non-traumatic or post-traumatic SAH patients. METHODS The MIMIC-III database was searched to select patients with SAH based on ICD-9 codes. Patients were separated into non-traumatic and post-traumatic SAH groups. Using LASSO regression analysis, we identified independent risk factors associated with 28-day mortality and incorporated them into nomogram models. The performance of each nomogram was assessed by calculating various metrics, including the area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA). RESULTS The study included 999 patients with SAH, with 631 in the non-traumatic group and 368 in the post-traumatic group. Logistic regression analysis revealed critical independent risk factors for 28-day mortality in non-traumatic SAH patients, including gender, age, glucose, platelet, sodium, BUN, WBC, PTT, urine output, SpO2, and heart rate and age, glucose, PTT, urine output, and body temperature for post-traumatic SAH patients. The prognostic nomograms outperformed the commonly used SAPSII and APSIII systems, as evidenced by superior AUC, NRI, IDI, and DCA results. CONCLUSION The study identified independent risk factors associated with the 28-day mortality risk and developed predictive nomogram models for both non-traumatic and post-traumatic SAH patients. The nomogram holds promise in guiding prognosis improvement strategies for patients with SAH.
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Affiliation(s)
- Guiqiang Miao
- Department of Orthopedics, Foshan Fosun Chancheng Hospital, Foshan, 528010, China
| | - Zhenbin Cai
- Department of Orthopedics, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Xin He
- Clinical Laboratory Center, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Jie Yang
- Department of Orthopedics, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Yunlong Zhang
- Department of Orthopedics, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Ao Ma
- Department of Orthopedics, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Xiaodong Zhao
- Department of Orthopedics, Foshan Fosun Chancheng Hospital, Foshan, 528010, China.
| | - Minghui Tan
- Department of Orthopedics, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China.
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Ran KR, Nair SK, Srinivas T, Xie ME, Kilgore CB, Ye X, Yedavalli VS, Sun LR, Jackson CM, Caplan JM, Gonzalez LF, Tamargo RJ, Huang J, Xu R. Hemoglobin Drop is Associated with Early Post-operative Stroke Following Revascularization Surgery for Moyamoya Disease. J Neurosurg Anesthesiol 2024:00008506-990000000-00109. [PMID: 38686811 DOI: 10.1097/ana.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Postoperative stroke is a potentially devastating neurological complication following surgical revascularization for Moyamoya disease. We sought to evaluate whether peri-operative hemoglobin levels were associated with the risk of early post-operative stroke following revascularization surgery in adult Moyamoya patients. METHODS Adult patients having revascularization surgeries for Moyamoya disease between 1999-2022 were identified through single institutional retrospective review. Logistic regression analysis was used to test for the association between hemoglobin drop and early postoperative stroke. RESULTS In all, 106 revascularization surgeries were included in the study. A stroke occurred within 7 days after surgery in 9.4% of cases. There were no significant associations between the occurrence of an early postoperative stroke and patient age, gender, or race. Mean postoperative hemoglobin drop was greater in patients who suffered an early postoperative stroke compared with patients who did not (2.3±1.1 g/dL vs. 1.3±1.1 g/dL, respectively; P=0.034). Patients who experienced a hemoglobin drop post-operatively had 2.03 times greater odds (95% confidence interval, 1.06-4.23; P=0.040) of having a stroke than those whose hemoglobin levels were stable. Early postoperative stroke was also associated with an increase in length of hospital stay (P<0.001), discharge to a rehabilitation facility (P=0.014), and worse modified Rankin scale at 1 month (P=0.001). CONCLUSION This study found a significant association between hemoglobin drop and early postoperative stroke following revascularization surgery in adult patients with Moyamoya disease. Based on our findings, it may be prudent to avoid hemoglobin drops in Moyamoya patients undergoing surgical revascularization.
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Affiliation(s)
| | | | | | | | | | | | | | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
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Autio AH, Paavola J, Tervonen J, Lång M, Huuskonen TJ, Huttunen J, Kärkkäinen V, von Und Zu Fraunberg M, Lindgren AE, Koivisto T, Kurola J, Jääskeläinen JE, Kämäräinen OP. Should individual timeline and serial CT/MRI panels of all patients be presented in acute brain insult cohorts? A pilot study of 45 patients with decompressive craniectomy after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:3299-3323. [PMID: 36715752 PMCID: PMC10624760 DOI: 10.1007/s00701-022-05473-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/20/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Our review of acute brain insult articles indicated that the patients' individual (i) timeline panels with the defined time points since the emergency call and (ii) serial brain CT/MRI slice panels through the neurointensive care until death or final brain tissue outcome at 12 months or later are not presented. METHODS We retrospectively constructed such panels for the 45 aneurysmal subarachnoid hemorrhage (aSAH) patients with a secondary decompressive craniectomy (DC) after the acute admission to neurointensive care at Kuopio University Hospital (KUH) from a defined population from 2005 to 2018. The patients were indicated by numbers (1.-45.) in the pseudonymized panels, tables, results, and discussion. The timelines contained up to ten defined time points on a logarithmic time axis until death ([Formula: see text]; 56%) or 3 years ([Formula: see text]; 44%). The brain CT/MRI panels contained a representative slice from the following time points: SAH diagnosis, after aneurysm closure, after DC, at about 12 months (20 survivors). RESULTS The timelines indicated re-bleeds and allowed to compare the times elapsed between any two time points, in terms of workflow swiftness. The serial CT/MRI slices illustrated the presence and course of intracerebral hemorrhage (ICH), perihematomal edema, intraventricular hemorrhage (IVH), hydrocephalus, delayed brain injury, and, in the 20 (44%) survivors, the brain tissue outcome. CONCLUSIONS The pseudonymized timeline panels and serial brain imaging panels, indicating the patients by numbers, allowed the presentation and comparison of individual clinical courses. An obvious application would be the quality control in acute or elective medicine for timely and equal access to clinical care.
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Affiliation(s)
- Anniina H Autio
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
| | - Juho Paavola
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Joona Tervonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Maarit Lång
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Neurointensive Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Terhi J Huuskonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jukka Huttunen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Virve Kärkkäinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Mikael von Und Zu Fraunberg
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Department of Neurosurgery, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Antti E Lindgren
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Timo Koivisto
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jouni Kurola
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Center for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Juha E Jääskeläinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Addis A, Baggiani M, Citerio G. Intracranial Pressure Monitoring and Management in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:59-69. [PMID: 37280411 PMCID: PMC10499755 DOI: 10.1007/s12028-023-01752-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 05/12/2023] [Indexed: 06/08/2023]
Abstract
Aneurysmal subarachnoid hemorrhage is a medical condition that can lead to intracranial hypertension, negatively impacting patients' outcomes. This review article explores the underlying pathophysiology that causes increased intracranial pressure (ICP) during hospitalization. Hydrocephalus, brain swelling, and intracranial hematoma could produce an ICP rise. Although cerebrospinal fluid withdrawal via an external ventricular drain is commonly used, ICP monitoring is not always consistently practiced. Indications for ICP monitoring include neurological deterioration, hydrocephalus, brain swelling, intracranial masses, and the need for cerebrospinal fluid drainage. This review emphasizes the importance of ICP monitoring and presents findings from the Synapse-ICU study, which supports a correlation between ICP monitoring and treatment with better patient outcomes. The review also discusses various therapeutic strategies for managing increased ICP and identifies potential areas for future research.
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Affiliation(s)
- Alberto Addis
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Neurological Intensive Care Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | | | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
- Neurological Intensive Care Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy.
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Bini G, Russo E, Antonini MV, Pirini E, Brunelli V, Zumbo F, Pronti G, Rasi A, Agnoletti V. Impact of early percutaneous dilatative tracheostomy in patients with subarachnoid hemorrhage on main cerebral, hemodynamic, and respiratory variables: A prospective observational study. Front Neurol 2023; 14:1105568. [PMID: 37051061 PMCID: PMC10083491 DOI: 10.3389/fneur.2023.1105568] [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: 11/22/2022] [Accepted: 03/02/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction Patients with poor-grade subarachnoid hemorrhage (SAH) admitted to the intensive care unit (ICU) often require prolonged invasive mechanical ventilation due to prolonged time to obtain neurological recovery. Impairment of consciousness and airway protective mechanisms usually require tracheostomy during the ICU stay to facilitate weaning from sedation, promote neurological assessment, and reduce mechanical ventilation (MV) duration and associated complications. Percutaneous dilatational tracheostomy (PDT) is the technique of choice for performing a tracheostomy. However, it could be associated with particular risks in neurocritical care patients, potentially increasing the risk of secondary brain damage. Methods We conducted a single-center, prospective, observational study aimed to assess PDT-associated variations in main cerebral, hemodynamic, and respiratory variables, the occurrence of tracheostomy-related complications, and their relationship with outcomes in adult patients with SAH admitted to the ICU of a neurosurgery/neurocritical care hub center after aneurysm control through clipping or coiling and undergoing early PDT. Results We observed a temporary increase in ICP during early PDT; this increase was statistically significant in patients presenting with higher therapy intensity level (TIL) at the time of the procedural. The episodes of intracranial hypertension were brief, and appeared mainly due to the activation of cerebral autoregulatory mechanisms in patients with impaired compensatory mechanisms and compliance. Discussion The low number of observed complications might be related to our organizational strategy, all based on a dedicated "tracheo-team" implementing both PDT following a strictly defined protocol and accurate follow-up.
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Affiliation(s)
- Giovanni Bini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Emanuele Russo
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Marta Velia Antonini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Erika Pirini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Valentina Brunelli
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Fabrizio Zumbo
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giorgia Pronti
- Department of Anesthesia and Intensive Care, Osspedale degli Infermi, Rimini, Italy
| | - Alice Rasi
- Department of Pediatrics, Ospedale Bufalini, Cesena (FC), Italy
| | - Vanni Agnoletti
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
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6
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McGlennen KM, Jannotta GE, Livesay SL. Nursing Management of Temperature in a Patient with Stroke. Crit Care Nurs Clin North Am 2023; 35:39-52. [PMID: 36774006 DOI: 10.1016/j.cnc.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Fever is common in patients with stroke and is associated with worse outcomes. Studies in brain injury informed interventions commonly termed therapeutic temperature management (TTM) to improve the monitoring and management of fever. While the role and benefit of TTM in stroke patients has not been well studied, the nurse and healthcare team must extrapolate existing data to determine how to best monitor and apply TTM after stroke. Nurses should be knowledgeable about interventions to monitor and manage complications of TTM (eg, shivering), the studies underway to quantify the impact of fever treatment and emerging technology expected to improve TTM.
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Affiliation(s)
| | - Gemi E Jannotta
- Department of Anesthesia and Pain Medicine, University of Washington
| | - Sarah L Livesay
- Department of Anesthesia and Pain Medicine, University of Washington, Rush University College of Nursing
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Yang X, Cao L, Zhang T, Qu X, Chen W, Cheng W, Qi M, Wang N, Song W, Wang N. More is less: Effect of ICF-based early progressive mobilization on severe aneurysmal subarachnoid hemorrhage in the NICU. Front Neurol 2022; 13:951071. [PMID: 36588882 PMCID: PMC9794623 DOI: 10.3389/fneur.2022.951071] [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: 06/21/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Aneurysmal subarachnoid hemorrhage (aSAH) is a type of stroke that occurs due to a ruptured intracranial aneurysm. Although advanced therapies have been applied to treat aSAH, patients still suffer from functional impairment leading to prolonged stays in the NICU. The effect of early progressive mobilization as an intervention implemented in the ICU setting for critically ill patients remains unclear. Methods This retrospective study evaluated ICF-based early progressive mobilization's validity, safety, and feasibility in severe aSAH patients. Sixty-eight patients with aSAH with Hunt-Hess grades III-IV were included. They were divided into two groups-progressive mobilization and passive movement. Patients in the progressive mobilization group received progressive ICF-based mobilization intervention, and those in the passive movement group received passive joint movement training. The incidence of pneumonia, duration of mechanical ventilation, length of NICU stay, and incidence of deep vein thrombosis were evaluated for validity. In contrast, the incidence of cerebral vasospasm, abnormally high ICP, and other safety events were assessed for safety. We also described the feasibility of the early mobilization initiation time and the rate of participation at each level for patients in the progressive mobilization group. Results The results showed that the incidence of pneumonia, duration of mechanical ventilation, and length of NICU stay were significantly lower among patients in the progressive mobilization group than in the passive movement group (P = 0.031, P = 0.004, P = 0.012), but the incidence of deep vein thrombosis did not significantly differ between the two groups. Regarding safety, patients in the progressive mobilization group had a lower incidence of cerebral vasospasm than those in the passive movement group. Considering the effect of an external ventricular drain on cerebral vasospasm (P = 0.015), we further analyzed those patients in the progressive mobilization group who had a lower incidence of cerebral vasospasm in patients who did not have an external ventricular drain (P = 0.011). Although we found 2 events of abnormally increased intracranial pressure in the progressive mobilization group, there was no abnormal decrease in cerebral perfusion pressure in the 2 events. In addition, among other safety events, there was no difference in the occurrence of adverse events between the two groups (P = 0.073), but the number of potential adverse events was higher in the progressive mobilization group (P = 0.001). Regarding feasibility, patients in the progressive mobilization group were commonly initiated 72 h after admission to the NICU, and 47.06% were in the third level of the mobilization protocol. Discussion We conclude that the ICF-based early progressive mobilization protocol is an effective and feasible intervention tool. For validity, more mobilization interventions might lead to less pneumonia, duration of mechanical ventilation and length of stay for patients with severe aSAH in the NICU, Moreover, it is necessary to pay attention over potential adverse events (especially line problems), although we did not find serious safety events.
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Affiliation(s)
- Xiaolong Yang
- Department of Rehabilitation Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lei Cao
- Department of Rehabilitation Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tiantian Zhang
- Department of Rehabilitation Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Qu
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenjin Chen
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weitao Cheng
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng Qi
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Na Wang
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weiqun Song
- Department of Rehabilitation Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China,*Correspondence: Weiqun Song
| | - Ning Wang
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,Ning Wang
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Won SY, Kim MK, Song J, Lim YC. Therapeutic hypothermia in patients with poor-grade aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2022; 221:107369. [DOI: 10.1016/j.clineuro.2022.107369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022]
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Shah VA, Kazmi SO, Damani R, Harris AH, Hohmann SF, Calvillo E, Suarez JI. Regional Variability in the Care and Outcomes of Subarachnoid Hemorrhage Patients in the United States. Front Neurol 2022; 13:908609. [PMID: 35785364 PMCID: PMC9243235 DOI: 10.3389/fneur.2022.908609] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/25/2022] [Indexed: 11/14/2022] Open
Abstract
Background and Objectives Regional variability in subarachnoid hemorrhage (SAH) care is reported in physician surveys. We aimed to describe variability in SAH care using patient-level data and identify factors impacting hospital outcomes and regional variability in outcomes. Methods A retrospective multi-center cross-sectional cohort study of consecutive non-traumatic SAH patients in the Vizient Clinical Data Base, between January 1st, 2009 and December 30th, 2018 was performed. Participating hospitals were divided into US regions: Northeast, Midwest, South, West. Regional demographics, co-morbidities, severity-of-illness, complications, interventions and discharge outcomes were compared. Multivariable logistic regression was performed to identify factors independently associated with primary outcomes: hospital mortality and poor discharge outcome. Poor discharge outcome was defined by the Nationwide Inpatient Sample-SAH Outcome Measure, an externally-validated outcome measure combining death, discharge disposition, tracheostomy and/or gastrostomy. Regional variability in the associations between care and outcomes were assessed by introducing an interaction term for US region into the models. Results Of 109,034 patients included, 24.3% were from Northeast, 24.9% Midwest, 34.9% South, 15.9% West. Mean (SD) age was 58.6 (15.6) years and 64,245 (58.9%) were female. In-hospital mortality occurred in 21,991 (20.2%) and 44,159 (40.5%) had poor discharge outcome. There was significant variability in severity-of-illness, co-morbidities, complications and interventions across US regions. Notable findings were higher prevalence of surgical clipping (18.8 vs. 11.6%), delayed cerebral ischemia (4.3 vs. 3.1%), seizures (16.5 vs. 14.8%), infections (18 vs. 14.7%), length of stay (mean [SD] days; 15.7 [19.2] vs. 14.1 [16.7]) and health-care direct costs (mean [SD] USD; 80,379 [98,999]. vs. 58,264 [74,430]) in the West when compared to other regions (all p < 0.0001). Variability in care was also associated with modest variability in hospital mortality and discharge outcome. Aneurysm repair, nimodipine use, later admission-year, endovascular rescue therapies reduced the odds for poor outcome. Age, severity-of-illness, co-morbidities, hospital complications, and vasopressor use increased those odds (c-statistic; mortality: 0.77; discharge outcome: 0.81). Regional interaction effect was significant for admission severity-of-illness, aneurysm-repair and nimodipine-use. Discussion Multiple hospital-care factors impact SAH outcomes and significant variability in hospital-care and modest variability in discharge-outcomes exists across the US. Variability in SAH-severity, nimodipine-use and aneurysm-repair may drive variability in outcomes.
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Affiliation(s)
- Vishank A. Shah
- Division of Neurosciences Critical Care, Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Vishank A. Shah
| | | | - Rahul Damani
- Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Alyssa Hartsell Harris
- Center for Advanced Analytics and Informatics, Vizient, Inc., Chicago, IL, United States
| | - Samuel F. Hohmann
- Center for Advanced Analytics and Informatics, Vizient, Inc., Chicago, IL, United States
| | - Eusebia Calvillo
- Division of Neurosciences Critical Care, Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jose I. Suarez
- Division of Neurosciences Critical Care, Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Wang Y, Xu J, You W, Shen H, Li X, Yu Z, Li H, Chen G. Roles of Rufy3 in experimental subarachnoid hemorrhage-induced early brain injury via accelerating neuronal axon repair and synaptic plasticity. Mol Brain 2022; 15:35. [PMID: 35461284 PMCID: PMC9034509 DOI: 10.1186/s13041-022-00919-6] [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: 12/12/2021] [Accepted: 04/06/2022] [Indexed: 11/25/2022] Open
Abstract
RUN and FYVE domain-containing 3 (Rufy3) is a well-known adapter protein of a small GTPase protein family and is bound to the activated Ras family protein to maintain neuronal polarity. However, in experimental subarachnoid hemorrhage (SAH), the role of Rufy3 has not been investigated. Consequently, we aimed to investigate the potential role of Rufy3 in an in vivo model of SAH-induced early brain injury (EBI). In addition, we investigated the relevant brain-protective mechanisms. Oxyhemoglobin (OxyHb) stimulation of cultured primary neurons simulated vitro SAH condition. The SAH rat model was induced by infusing autologous blood into the optic chiasma pool and treating the rats with lentivirus-negative control 1 (LV-NC1), lentivirus-Rufy3 shRNA (LV-shRNA), lentivirus-negative control 2 (LV-NC2), lentivirus-Rufy3 (LV-Rufy3), or 8-pCPT-2′-O-Me-cAMP (8p-CPT) (Rap1 agonist). In experiment one, we found that the protein level of Rufy3 decreased and neuronal axon injury in the injured neurons but was rectified by LV-Rufy3 treatment. In experiment two, mRNA and protein levels of Rufy3 were downregulated in brain tissue and reached the lowest level at 24 h after SAH. In addition, the expression of Myelin Basic Protein was downregulated and that of anti-hypophosphorylated neurofilament H (N52) was upregulated after SAH. In experiments three and four, Rufy3 overexpression (LV-Rufy3) increased the interactions between Rufy3 and Rap1, the level of Rap1-GTP, and the ratio of Rap1-GTP/total GTP. In addition, LV-Rufy3 treatment inhibited axon injury and accelerated axon repair by activating the Rap1/Arap3/Rho/Fascin signaling pathway accompanied by upregulated protein expression levels of ARAP3, Rho, Fascin, and Facin. LV-Rufy3 also enhanced synaptic plasticity by activating the Rap1/MEK/ERK/synapsin I signaling pathway accompanied by upregulated protein expression levels of ERK1, p-ERK1, MEK1, p-MEK1, synaspin I, and p-synaspin I. Moreover, LV-Rufy3 also alleviated brain damage indicators, including cortical neuronal cell apoptosis and degeneration, brain edema, and cognitive impairment after SAH. However, the downregulation of Rufy3 had the opposite effect and aggravated EBI induced by SAH. Notably, the combined application of LV-Rufy3 and 8p-CPT showed a significant synergistic effect on the aforementioned parameters. Our findings suggest that enhanced Rufy3 expression may reduce EBI by inhibiting axon injury and promoting neuronal axon repair and synaptic plasticity after SAH.
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Affiliation(s)
- Yang Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China.,Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Jianguo Xu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Wanchun You
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Haitao Shen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Xiang Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Zhengquan Yu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China.
| | - Haiying Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China.
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
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11
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Al-Mufti F, Mayer SA, Kaur G, Bassily D, Li B, Holstein ML, Ani J, Matluck NE, Kamal H, Nuoman R, Bowers CA, S Ali F, Al-Shammari H, El-Ghanem M, Gandhi C, Amuluru K. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism. Neuroradiol J 2021; 34:542-551. [PMID: 34476991 PMCID: PMC8649190 DOI: 10.1177/19714009211024633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Daniel Bassily
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Boyi Li
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Matthew L Holstein
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Jood Ani
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Nicole E Matluck
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Maria Fareri Children’s Hospital, Westchester Medical Center, Valhalla, USA
| | | | - Faizan S Ali
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Hussein Al-Shammari
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA
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12
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Anthofer J, Bele S, Wendl C, Kieninger M, Zeman F, Bruendl E, Schmidt NO, Schebesch KM. Continuous intra-arterial nimodipine infusion as rescue treatment of severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2021; 96:163-171. [PMID: 34789415 DOI: 10.1016/j.jocn.2021.10.028] [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: 11/03/2020] [Revised: 08/30/2021] [Accepted: 10/24/2021] [Indexed: 11/29/2022]
Abstract
Severe refractory cerebral vasospasm (CV) is a major cause of disability and death in patients with aneurysmal subarachnoid hemorrhage (SAH). One rescue therapy in selected patients is intra-arterial nimodipine, either given as a single shot or as continuous infusion. To evaluate treatment efficacy, we analyzed outcome factors such as the incidence of craniectomy, ventriculo-peritonial (VP) shunting, and tracheotomy after intra-arterial nimodipine infusion. We retrospectively analyzed the rates of cerebral infarction, decompressive craniectomy, VP shunting, and tracheotomy in patients with severe CV after SAH. Three different patient groups were compared: group 1 had only been treated with oral nimodipine and hypervolemic hypertensive therapy (HHT) (2006-2010), group 2 with a single shot of intra-arterial nimodipine (SSN) in addition to oral conservative treatment (2006-2010), and group 3 with continuous intra-arterial nimodipine (CIAN) (2011-2017). The incidence of cerebral infarction was significantly lower in CIAN group (p = 0.005) than in conservative and SSN group. The indication for consecutive decompressive craniectomy was significantly lower in CIAN group in comparison with the conservative group (p = 0.018). The rates of VP shunting and tracheotomy were significantly higher in the CIAN group than in the conservative group (p = 0.028 for VP, and p = 0.003 for tracheotomy). The significantly lower rate of craniectomy in the CIAN group was most probably attributable to the significantly lower rate of CV-induced infarction. The higher rate of tracheotomy reflects more extensive sedation and the need of longer stays on the intensive care unit. Thus, the effect on long-term neurological outcome and quality of life has to be evaluated separately.
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Affiliation(s)
- Judith Anthofer
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany.
| | - Sylvia Bele
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Christina Wendl
- Department of Neuroradiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Elisabeth Bruendl
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Nils-Ole Schmidt
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
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13
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Abstract
Hyperventilation is commonly used in neurological patients to decrease elevated intracranial pressure (ICP) or relax a tense brain. However, the potentially deleterious effects of hyperventilation may limit its clinical application. The aim of this review is to summarize the physiological and outcome evidence related to hyperventilation in neurological patients.
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