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Khosdelazad S, Spikman JM, Solvang S, Wermer MJH, Pender N, Jorna LS, Rakers SE, van der Hoorn A, Javadpour M, Groen RJM, Buunk AM. Re-evaluating patient communication and care in angiographically negative subarachnoid hemorrhage: Balancing realism and optimism. Eur J Neurol 2024; 31:e16257. [PMID: 38491735 PMCID: PMC11235759 DOI: 10.1111/ene.16257] [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: 12/18/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 03/18/2024]
Abstract
Angiographically negative subarachnoid hemorrhage (anSAH) has traditionally been considered a benign condition, mainly because of favorable outcomes in the acute stage in comparison to the often negative acute outcomes of aneurysmal subarachnoid hemorrhage. However, a growing body of research in recent years shows that anSAH often leads to cognitive impairments, emotional distress, and difficulties in resuming work or other daily life activities. Therefore, in this position paper, we call for a change in neurological care and a shift in patient communication, emphasizing the importance of addressing patient needs and fostering realistic expectations rather than solely focusing on the benign nature of the condition.
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Affiliation(s)
- Sara Khosdelazad
- Department of Neurology, Unit Neuropsychology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Jacoba M. Spikman
- Department of Neurology, Unit Neuropsychology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Department of Behavioral and Social SciencesUniversity of GroningenGroningenThe Netherlands
| | - Sofie Solvang
- Department of Neurology, Unit Neuropsychology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Marieke J. H. Wermer
- Department of Neurology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Niall Pender
- Department of PsychologyBeaumont HospitalDublinIreland
| | - Lieke S. Jorna
- Department of Neurology, Unit Neuropsychology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Sandra E. Rakers
- Department of Neurology, Unit Neuropsychology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Department of Behavioral and Social SciencesUniversity of GroningenGroningenThe Netherlands
| | - Anouk van der Hoorn
- Department of Radiology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | | | - Rob J. M. Groen
- Department of Neurosurgery, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Department of Neurosurgery, Faculty of Medicine Universitas AirlanggaDr. Soetomo General Academic HospitalSurabayaIndonesia
| | - Anne M. Buunk
- Department of Neurology, Unit Neuropsychology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Department of Behavioral and Social SciencesUniversity of GroningenGroningenThe Netherlands
- Department of Neurosurgery, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
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Lu G, Wang C, Zhao L, Shi H, Liu S. Clinical Outcomes of Diffuse Angiogram-Negative Subarachnoid Hemorrhage Versus Aneurysmal Subarachnoid Hemorrhage: A Propensity Score-Matched Analysis. J Am Heart Assoc 2024; 13:e031066. [PMID: 38156544 PMCID: PMC10863825 DOI: 10.1161/jaha.123.031066] [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: 05/18/2023] [Accepted: 11/28/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND The outcome of diffuse angiogram-negative subarachnoid hemorrhage (dan-SAH) compared with aneurysmal SAH (aSAH) remains unclear. This study aimed to compare outcomes using propensity score matching. METHODS AND RESULTS Sixty-five patients with dan-SAH and 857 patients with aSAH admitted between January 2018 and December 2022 were retrospectively reviewed. Propensity score matching resulted in matching 65 patients with dan-SAH to 260 patients with aSAH, and clinical outcomes were compared between the groups. Compared with patients with dan-SAH, patients with aSAH were more likely to experience rehemorrhage (8.8% versus 0%, P=0.027), death (11.2% versus 1.5%; odds ratios [OR] 8.04 [95% CI, 1.07-60.12]; P=0.042), or delayed cerebral ischemia (12.3% versus 3.1%; OR, 4.42 [95% CI, 1.03-18.95]; P=0.045). Multivariate analysis revealed that Hunt-Hess grade 4 to 5 (OR, 3.13 [95% CI, 2.11-4.64]; P<0.001), presence of intraventricular hemorrhage (OR, 3.58 [95% CI, 1.72-7.46]; P=0.001), and smoking (OR, 2.44 [95% CI, 1.12-5.28]; P=0.024) were independently associated with the incidence of unfavorable outcomes (modified Rankin scale score >2 at 3 months), whereas dan-SAH was not (OR, 0.66 [95% CI, 0.25-1.73]; P=0.40). CONCLUSIONS Compared with patients with dan-SAH, patients with aSAH had higher rehemorrhage rates and in-hospital mortality, as well as a higher incidence of delayed cerebral ischemia. Unfavorable outcomes were associated with admission Hunt-Hess grade, the presence of intravenetricular hemorrhage, and smoking history, but there was no relation with the pathogenesis of the hemorrhage (dan-SAH versus aSAH).
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Affiliation(s)
- Guang‐Dong Lu
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Cheng Wang
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Lin‐Bo Zhao
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Hai‐Bin Shi
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Sheng Liu
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
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Roman-Filip I, Morosanu V, Bajko Z, Roman-Filip C, Balasa RI. Non-Aneurysmal Perimesencephalic Subarachnoid Hemorrhage: A Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13061195. [PMID: 36980503 PMCID: PMC10047780 DOI: 10.3390/diagnostics13061195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Spontaneous non-aneurysmal subarachnoid haemorrhage (NAPMSAH) (addressing point 1) is a relatively rare occurrence in clinical settings as it is rarely misdiagnosed and usually involves a significantly better prognosis than the classical aneurysmal pattern. We hereby focused on a comprehensive analysis of this distinct pathological entity with the purpose of analysing possible pathophysiological entities, outcomes and treatment options involving this diagnosis with a focus on demographical, epidemiological and clinical data. The clinical setting includes focal neurological signs related to the anatomical structures, while computer tomography followed by tomographic angiography are the most common diagnosis tools, with a typical hyperdense lesion involving the midbrain, fourth ventricle and subthalamic areas without an angiographic correspondent, such as an aneurysmal pathology. Further investigations can also be used to highlight this diagnosis, such as interventional angiography or magnetic resonance imaging. Given the rarity of this condition and its relatively better prognosis, treatment options usually remain conservative. In the present review, the main characteristics of NAPMSAH are discussed.
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Affiliation(s)
- Iulian Roman-Filip
- Department of Neurology, "George Emil Palade" University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Valentin Morosanu
- Department of Neurology, "George Emil Palade" University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Zoltan Bajko
- Department of Neurology, "George Emil Palade" University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Corina Roman-Filip
- Department of Neurology, "Lucian Blaga" University of Sibiu Faculty of Medicine, 550169 Sibiu, Romania
| | - Rodica Ioana Balasa
- Department of Neurology, "George Emil Palade" University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
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Hakimi R. Imaging of Central Nervous System Hemorrhage. Continuum (Minneap Minn) 2023; 29:73-103. [PMID: 36795874 DOI: 10.1212/con.0000000000001219] [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: 02/18/2023]
Abstract
OBJECTIVE This article aims to familiarize the reader with the various types of nontraumatic central nervous system (CNS) hemorrhage and the various neuroimaging modalities used to help diagnose and manage them. LATEST DEVELOPMENTS According to the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study, intraparenchymal hemorrhage accounts for 28% of the global stroke burden. In the United States, hemorrhagic stroke makes up 13% of all strokes. The incidence of intraparenchymal hemorrhage increases substantially with age; thus, despite improvements in blood pressure control through various public health measures, the incidence is not decreasing as the population ages. In fact, in the most recent longitudinal study of aging, autopsy findings showed intraparenchymal hemorrhage and cerebral amyloid angiopathy in 30% to 35% of patients. ESSENTIAL POINTS Rapid identification of CNS hemorrhage, which includes intraparenchymal hemorrhage, intraventricular hemorrhage, and subarachnoid hemorrhage, requires either head CT or brain MRI. Once hemorrhage is identified on the screening neuroimaging study, the pattern of blood in conjunction with the history and physical examination can guide subsequent neuroimaging, laboratory, and ancillary tests as part of the etiologic assessment. After determination of the cause, the chief aims of the treatment regimen are reducing hemorrhage expansion and preventing subsequent complications such as cytotoxic cerebral edema, brain compression, and obstructive hydrocephalus. In addition, nontraumatic spinal cord hemorrhage will also be briefly discussed.
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Baumgartner K, Meyer A, Mandel D, Moody S, Wendell L, Thompson BB, Subramaniam T, Reznik ME, Furie KL, Mahta A. Radiographic predictors of aneurysmal etiology in patients with aneurysmal pattern subarachnoid hemorrhage. J Neurosurg 2022:1-7. [PMID: 36727566 DOI: 10.3171/2022.11.jns222192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Spontaneous angiogram-negative nonperimesencephalic subarachnoid hemorrhage (an-NPSAH) can represent a diagnostic and management dilemma. The authors sought to determine radiographic predictors of aneurysmal etiology based on admission noncontrast head CT scans. METHODS The authors performed a retrospective cohort study of prospectively collected data from consecutive patients who were admitted for spontaneous subarachnoid hemorrhage (SAH) with suspected aneurysmal etiology to an academic center from 2016 to 2021. They compared blood thickness in the basal cisterns and sylvian fissures and modified Graeb scores on admission head CT scans between the two groups and subsequently developed a predictive model to identify aneurysmal etiology. RESULTS Of 259 included patients (mean age 56 years [SD 12.7 years]; 55% female), 209 had aneurysmal SAH (aSAH) and 50 had an-NPSAH. The median modified Graeb scores were similar for aSAH and an-NPSAH (6 [IQR 2-10] vs 3.5 [IQR 0-8.5], p = 0.33). The mean blood thickness was greater in the sylvian fissure (p = 0.010) and interhemispheric cisterns (p = 0.002), and there was a greater median degree of extension of blood in the sylvian fissures (p = 0.001) in aSAH than in an-NPSAH patients, but the mean blood thickness was less in the prepontine cistern (p = 0.014). The authors' scoring model was constructed based on differences in radiographic features. Receiver operating characteristic curve analysis showed acceptable accuracy in predicting aneurysmal etiology (area under the curve 0.71, 95% CI 0.62-0.79). CONCLUSIONS There are differences in radiographic features on admission head CT between an-NPSAH and aSAH patients. The authors' proposed risk stratification model may be considered for further development and use in clinical practice in the future. ABBREVIATIONS an-NPSAH = angiogram-negative nonperimesencephalic SAH; aSAH = aneurysmal SAH; DSA = digital subtraction angiography; LOS = length of stay; NCHCT = noncontrast head CT; ROC = receiver operating characteristic; SAH = subarachnoid hemorrhage.
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Affiliation(s)
| | | | | | | | - Linda Wendell
- Division of Neurology, Mount Auburn Hospital, Cambridge, Massachusetts; and
| | - Bradford B. Thompson
- Departments of Neurology and
- Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Thanujaa Subramaniam
- Departments of Neurology and
- Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael E. Reznik
- Departments of Neurology and
- Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Ali Mahta
- Departments of Neurology and
- Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Khosdelazad S, Jorna LS, Groen RJM, Rakers SE, Timmerman ME, Borra RJH, van der Hoorn A, Spikman JM, Buunk AM. Investigating Recovery After Subarachnoid Hemorrhage With the Imaging, Cognition and Outcome of Neuropsychological Functioning After Subarachnoid Hemorrhage (ICONS) Study: Protocol for a Longitudinal, Prospective Cohort Study. JMIR Res Protoc 2022; 11:e38190. [PMID: 36173673 PMCID: PMC9562051 DOI: 10.2196/38190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/26/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background A subarachnoid hemorrhage is a hemorrhage in the subarachnoid space that is often caused by the rupture of an aneurysm. Patients who survive a subarachnoid hemorrhage have a high risk of complications and a negative long-term outcome. Objective The aim of the Imaging, Cognition and Outcome of Neuropsychological functioning after Subarachnoid hemorrhage (ICONS) study is to investigate whether and to what extent deficits exist in multiple domains after subarachnoid hemorrhage, including cognition, emotion and behavior, and to investigate whether brain damage can be detected in patients with subarachnoid hemorrhage. We aim to determine which early measures of cognition, emotion and behavior, and brain damage in the subacute stage play a role in long-term recovery after subarachnoid hemorrhage. Recovery is defined as functioning at a societal participation level, with a focus on resuming and maintaining work, leisure activities, and social relationships over the long term. Methods The ICONS study is an observational, prospective, single-center cohort study. The study includes patients with subarachnoid hemorrhage admitted to the Neurosurgery Unit of the University Medical Centre Groningen in the Netherlands. The inclusion criteria include diagnosis of an aneurysmal subarachnoid hemorrhage or an angiographically negative subarachnoid hemorrhage, sufficient ability in the Dutch language, and age older than 18 years. Patients will undergo neuropsychological assessment and magnetic resonance imaging 6 months after the subarachnoid hemorrhage. Furthermore, patients will be asked to fill in questionnaires on multiple psychosocial measures and undergo a structured interview at 6 months, 1 year, and 2 years after the subarachnoid hemorrhage. The primary outcome measure of the ICONS study is societal participation 1 year after the subarachnoid hemorrhage, measured with the Dutch version of the Impact on Participation and Autonomy questionnaire. Results The study was launched in December 2019 and recruitment is expected to continue until June 2023. At the time of the acceptance of this paper, 76 patients and 69 healthy controls have been included. The first results are expected in early 2023. Conclusions The ICONS study is the first to collect and combine data after subarachnoid hemorrhage in a variety of domains, including cognition, emotion and behavior, and brain damage. The results will contribute to a more comprehensive understanding of the consequences of both aneurysmal subarachnoid hemorrhage and angiographically negative subarachnoid hemorrhage, which may ultimately optimize timely treatment for this patient group by setting realistic and attainable goals to improve daily functioning. Trial Registration Netherlands Trial Register NL7803; https://trialsearch.who.int/Trial2.aspx?TrialID=NL7803 International Registered Report Identifier (IRRID) DERR1-10.2196/38190
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Affiliation(s)
- Sara Khosdelazad
- Neuropsychology Unit, Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Lieke S Jorna
- Neuropsychology Unit, Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Rob J M Groen
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Sandra E Rakers
- Neuropsychology Unit, Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Marieke E Timmerman
- Department of Psychometrics and Statistics, University of Groningen, Groningen, Netherlands
| | - Ronald J H Borra
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Anouk van der Hoorn
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jacoba M Spikman
- Neuropsychology Unit, Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Anne M Buunk
- Neuropsychology Unit, Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
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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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Hou K, Yu J. Current status of perimesencephalic non-aneurysmal subarachnoid hemorrhage. Front Neurol 2022; 13:960702. [PMID: 36119687 PMCID: PMC9475169 DOI: 10.3389/fneur.2022.960702] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/08/2022] [Indexed: 01/21/2023] Open
Abstract
Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a distinctive disease, representing SAH centered in perimesencephalic cisterns, with negative angiography findings. In recent years, the number of patients with PNSAH has increased significantly; however, the knowledge of PNSAH is insufficient. Therefore, we performed a review of the literature from a PubMed search and recounted our understanding of PNSAH. In this review, we summarized that current high-resolution computed tomography angiography is an acceptable replacement for digital subtraction angiography to rule out aneurysms in PNSAH with strict criteria. The current hypothesis about the etiology of PNSAH is that there is deep vein rupture from aberrant venous anatomy and increased intracranial venous pressure. PNSAH is associated with mild symptoms and lower rates of hydrocephalus and symptomatic vasospasm. For PNSAH, conservative treatment has been the mainstream treatment. PNSAH has a benign clinical course and an excellent prognosis; in long-term follow-up, re-bleeding and death were uncommon.
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Angermann M, Jablawi F, Angermann M, Conzen-Dilger C, Schubert GA, Höllig A, Veldeman M, Reich A, Hasan D, Ridwan H, Clusmann H, Wiesmann M, Nikoubashman O. Clinical Outcome and Prognostic Factors of Patients with Perimesencephalic and Nonperimesencephalic Subarachnoid Hemorrhage. World Neurosurg 2022; 165:e512-e519. [PMID: 35753679 DOI: 10.1016/j.wneu.2022.06.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To demonstrate the clinical outcome of patients with nonperimesencephalic subarachnoid hemorrhage (npSAH) compared with patients with aneurysmal SAH (aSAH) and perimesencephalic SAH (pSAH) and to evaluate predictive value of various clinical and radiological findings in patients with npSAH. METHODS We retrospectively identified patients with SAH who presented at our institution between 2009 and 2018. We analyzed demographic and clinical data and outcomes. Multivariable analysis was performed for outcome parameters. RESULTS Of 608 patients with confirmed SAH, 78% had aSAH, and 22% had nonaneurysmal SAH. Nonaneurysmal SAH was perimesencephalic in 30% of cases and nonperimesencephalic in 70%. Initial clinical status (Hunt and Hess score) was significantly worse in patients with aSAH compared with patients with nonaneurysmal SAH. Complications such as delayed cerebral ischemia occurred significantly more often in patients with aSAH. Patients with pSAH had a more favorable clinical course than patients with aSAH or npSAH. There was no significant difference in 30-day mortality between aSAH (29%) and npSAH (28%) patients (P = 0.835). Hunt and Hess score emerged as a strong predictor of unfavorable outcome in both aSAH and npSAH in multivariable regression. CONCLUSIONS Patients with npSAH had a similar clinical outcome as patients with aSAH, although there were significantly fewer clinical complications in patients with npSAH. Patients with pSAH demonstrated an overall good clinical course. Our multivariable analysis showed that initial Hunt and Hess score was an important predictor for clinical outcome in aSAH as well as npSAH.
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Affiliation(s)
- Manuel Angermann
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Fidaa Jablawi
- Department of Neurosurgery, Justus Liebig University Giessen, Giessen, Germany
| | - Maike Angermann
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Gerrit A Schubert
- Department of Neurosurgery, Kantontsspital Aarau, Aarau, Switzerland
| | - Anke Höllig
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
| | - Dimah Hasan
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Hani Ridwan
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany.
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Nguyen I, Caton MT, Tonetti D, Abla A, Kim A, Smith W, Hetts SW. Angiographically Occult Subarachnoid Hemorrhage: Yield of Repeat Angiography, Influence of Initial CT Bleed Pattern, and Sources of Diagnostic Error in 242 Consecutive Patients. AJNR Am J Neuroradiol 2022; 43:731-735. [PMID: 35361576 PMCID: PMC9089267 DOI: 10.3174/ajnr.a7483] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Nearly 20% of patients with spontaneous SAH have no definitive source on initial DSA. The purpose of this study was to investigate the timing and yield of repeat DSA, to clarify the influence of initial CT bleed pattern, and to characterize sources of diagnostic error in this scenario. MATERIALS AND METHODS We evaluated the yield of repeat DSA and clinical outcomes stratified by hemorrhage pattern on CT in consecutive patients with nontraumatic SAH with negative initial DSA findings at a referral center. Cases in which the culprit lesion was subsequently diagnosed were classified as physiologically occult (ie, undetectable) on the initial DSA, despite adequate technique and interpretation or misdiagnosed due to operator-dependent error. RESULTS Two hundred forty-two of 1163 (20.8%) patients with spontaneous SAH had negative initial DSA findings between 2009 and 2018. The SAH CT pattern was nonperimesencephalic (41%), perimesencephalic (36%), sulcal (18%), and CT-negative (5%). Repeat DSA in 135/242 patients (55.8%) revealed a source in 10 patients (7.4%): 4 saccular aneurysms, 4 atypical aneurysms, and 2 arteriovenous shunts. The overall yield of repeat DSA was 11.3% with nonperimesencephalic and 2.2% for perimesencephalic patterns. The yield of the second and third DSAs with a nonperimesencephalic pattern was 7.7% and 12%, respectively. Physiologically occult lesions accounted for 6/242 (2.5%) and operator-dependent errors accounted for 7/242 (2.9%) of all angiographically occult lesions on the first DSA. CONCLUSIONS Atypical aneurysms and small arteriovenous shunts are important causes of SAH negative on angiography. Improving DSAs technique can modestly reduce the need for repeat DSA; however, a small fraction of SAH sources remain occult despite adequate technique. These findings support the practice of repeating DSA in patients with a nonperimesencephalic SAH pattern.
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Affiliation(s)
- I Nguyen
- From the Department of Neurology (I.N.), University of California, Davis, Sacramento, California
- Department of Neurology (I.N., A.K., W.S.)
| | - M T Caton
- Radiology and Biomedical Imaging (M.T.C., S.W.H.)
| | - D Tonetti
- Neurological Surgery (D.T., A.A.), University of California, San Francisco, San Francisco, California
| | - A Abla
- Neurological Surgery (D.T., A.A.), University of California, San Francisco, San Francisco, California
| | - A Kim
- Department of Neurology (I.N., A.K., W.S.)
| | - W Smith
- Department of Neurology (I.N., A.K., W.S.)
| | - S W Hetts
- Radiology and Biomedical Imaging (M.T.C., S.W.H.)
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11
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Akbik F, Pimentel-Farias C, Press DA, Foster NE, Luu K, Williams MG, Andea SG, Kyei RK, Wetsel GM, Grossberg JA, Howard BM, Tong F, Cawley CM, Samuels OB, Sadan O. Diffuse Angiogram-Negative Subarachnoid Hemorrhage is Associated with an Intermediate Clinical Course. Neurocrit Care 2021; 36:1002-1010. [PMID: 34932193 DOI: 10.1007/s12028-021-01413-y] [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: 08/24/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The cerebral angiography result is negative for an underlying vascular lesion in 15-20% of patients with nontraumatic subarachnoid hemorrhage (SAH). Patients with angiogram-negative SAH include those with perimesencephalic SAH and diffuse SAH. Consensus suggests that perimesencephalic SAH confers a more favorable prognosis than diffuse SAH. Limited data exist to contextualize the clinical course and prognosis of diffuse SAH in relation to aneurysmal SAH in terms of critical care complications, neurologic complications, and functional outcomes. Here we compare the clinical course and functional outcomes of patients with perimesencephalic SAH, diffuse SAH, and aneurysmal SAH to better characterize the prognostic implications of each SAH subtype. METHODS We conducted a retrospective cohort study that included all patients with nontraumatic SAH admitted to a tertiary care referral center between January 1, 2012, and December 31, 2017. Bleed patterns were radiographically adjudicated, and patients were assigned to three groups: perimesencephalic SAH, diffuse SAH, and aneurysmal SAH. Patient demographics, complications, and clinical outcomes were reported and compared. RESULTS Eighty-six patients with perimesencephalic SAH, 174 with diffuse SAH, and 998 with aneurysmal SAH presented during the study period. Patients with aneurysmal SAH were significantly more likely to be female, White, and active smokers. There were no significant differences between patients with diffuse SAH and perimesencephalic SAH patterns. Critical care complications were compared across all three groups, with significant between-group differences in hypotension and shock (3.5% vs. 16.1% vs. 38.4% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01) and endotracheal intubation (0% vs. 26.4% vs. 48.8% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01). Similar trends were noted with long-term supportive care with tracheostomy and gastrostomy tubes and length of stay. Cerebrospinal fluid diversion was increasingly required across bleed types (9.3% vs. 54.6% vs. 76.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively, p < 0.001). Vasospasm and delayed cerebral ischemia were comparable between perimesencephalic SAH and diffuse SAH but significantly lower than aneurysmal SAH. Patients with diffuse SAH had intermediate functional outcomes, with significant rates of nonhome discharge (23.0%) and poor functional status on discharge (26.4%), significantly higher than patients with perimesencephalic SAH and lower than patients with aneurysmal SAH. Diffuse SAH similarly conferred an intermediate rate of good functional outcomes at 1-6 months post discharge (92.3% vs. 78.6% vs. 47.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.016). CONCLUSIONS We confirm the consensus data that perimesencephalic SAH is associated with a more benign clinical course but demonstrate that diffuse SAH confers an intermediate prognosis, more malignant than perimesencephalic SAH but not as morbid as aneurysmal SAH. These results highlight the significant morbidity associated with diffuse SAH and emphasize need for vigilance in the acute care of these patients. These patients will likely benefit from continued high-acuity observation and potential support to avert significant risk of morbidity and neurologic compromise.
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Affiliation(s)
- Feras Akbik
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA. .,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.
| | - Cederic Pimentel-Farias
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Di'Jonai A Press
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Niara E Foster
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Kevin Luu
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Merin G Williams
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Sena G Andea
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Regina K Kyei
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Grace M Wetsel
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - Brian M Howard
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - Frank Tong
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - C Michael Cawley
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - Owen B Samuels
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Ofer Sadan
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
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12
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Baseline characteristics and outcome for aneurysmal versus non-aneurysmal subarachnoid hemorrhage: a prospective cohort study. Neurosurg Rev 2021; 45:1413-1420. [PMID: 34604940 PMCID: PMC8976787 DOI: 10.1007/s10143-021-01650-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/24/2021] [Accepted: 09/20/2021] [Indexed: 12/25/2022]
Abstract
This study aims to investigate the characteristics of patients with mild aneurysmal and non-aneurysmal perimesencephalic and non-perimesencephalic subarachnoid hemorrhage (aSAH, pmSAH, npmSAH) with emphasis on admission biomarkers, clinical course, and outcome. A prospective cohort of 115 patients with aSAH (Hunt and Hess 1–3) and of 35 patients without aneurysms (16 pmSAH and 19 npmSAH) admitted between January 2014 and January 2020 was included. Demographic data, blood samples on admission, complications (hydrocephalus, shunt dependency, delayed cerebral ischemia DCI, DCI-related infarction, and mortality), and outcome after 6 months were analyzed. Demographic data was comparable between all groups except for age (aSAH 55 [48–65] vs. npmSAH 60 [56–68] vs. pmSAH 52 [42–60], p = 0.032) and loss of consciousness (33% vs. 0% vs. 0%, p = 0.0004). Admission biomarkers showed poorer renal function and highest glucose levels for npmSAH patients. Complication rate in npmSAH was high and comparable to that of aSAH patients (hydrocephalus, shunt dependency, DCI, DCI-related infarction, mortality), but nearly absent in patients with pmSAH. Favorable outcome after 6 months was seen in 92.9% of pmSAH, 83.3% of npmSAH, and 62.7% of aSAH (p = 0.0264). In this prospective cohort of SAH patients, npmSAH was associated with a complicated clinical course, comparable to that of patients with aSAH. In contrast, such complications were nearly absent in pmSAH patients, suggesting fundamental differences in the pathophysiology of patients with different types of non-aneurysmal hemorrhage. Our findings underline the importance for a precise terminology according the hemorrhage etiology as a basis for more vigilant management of npmSAH patients. NCT02142166, 05/20/2014, retrospectively registered.
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13
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Repeat Catheter Angiography in Patients with Aneurysmal-Pattern Angiographically Negative Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:52-60. [PMID: 34184178 DOI: 10.1007/s12028-021-01247-8] [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: 11/20/2020] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND A significant proportion of patients with subarachnoid hemorrhage have a normal cerebral angiogram. Patients with angiographically negative subarachnoid hemorrhage (anSAH) with either perimesencephalic- (panSAH) or aneurysmal-pattern hemorrhage (aanSAH, also known as diffuse anSAH) have an excellent prognosis, but only if underlying vascular abnormalities are completely excluded. The rate of occult aneurysms in patients with aanSAH varies widely across studies. The purpose of this study was to quantify the value of repeat DSA in these patients. METHODS We reviewed the records of all patients initially diagnosed with aanSAH after a screening DSA at a single tertiary neurovascular referral center from January 2006-April 2018. Patients with panSAH and traumatic SAH were excluded. We also performed a systematic review and meta-analysis of positive second DSAs in previously published case series of patients with aanSAH who underwent two serial DSAs. For meta-analysis, PubMed Central, MEDLINE and Cochrane Library databases were searched for pertinent studies up to November 2019. The rate of aneurysm detection on repeat angiography was extracted from each study. Pooled rates for positive second angiogram were calculated as untransformed proportions in a binary random-effects model meta-analysis. Inter-study heterogeneity was calculated using an I2 statistic. RESULTS Three of 27 patients (11.1%) with aanSAH and at least two DSAs were subsequently found to have a cerebral aneurysm in our institutional dataset. Twenty-six studies in our systematic review met inclusion criteria, and the pooled rate of positive second angiogram was 10.4% (95% CI 7.3%-13.5%, P < 0.001). Substantial inter-study heterogeneity was observed in the meta-analysis (I2 = 61.7%, P < 0.001). CONCLUSIONS One in 10 patients with aanSAH has an occult ruptured aneurysm. A second-look DSA should be strongly considered in these cases.
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14
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Scheitler KM, Nesvick CL, Wijdicks EF. Pretruncal Subarachnoid Hemorrhage in a Patient with Cerebrospinal Fluid Leak. Neurocrit Care 2020; 34:350-353. [PMID: 32588332 DOI: 10.1007/s12028-020-01030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Kristen M Scheitler
- Department of Neurological Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Cody L Nesvick
- Department of Neurological Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Eelco F Wijdicks
- Department of Neurocritical Care and Hospital Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA.
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15
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Roelz R, Schaefer JH, Scheiwe C, Sajonz B, Csok I, Steiert C, Buttler J, Rohr E, Grauvogel J, Shah MJ, Egger K, Niesen WD, Bardutzky J, Beck J, Coenen VA, Reinacher PC. Impact of Stereotactic Ventriculocisternostomy on Delayed Cerebral Infarction and Outcome After Subarachnoid Hemorrhage. Stroke 2019; 51:431-439. [PMID: 31795898 DOI: 10.1161/strokeaha.119.027424] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Delayed cerebral infarction (DCI) is an important cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Stereotactic catheter ventriculocisternostomy (STX-VCS) and fibrinolytic/spasmolytic lavage is a new method for DCI prevention. Here, we assess the effects of implementing STX-VCS in an unselected aSAH patient population of a tertiary referral center. Methods- Retrospective cohort study of all consecutive aSAH patients admitted to a neurosurgical referral center during a 7-year period (April 2012 to April 2019). Midterm STX-VCS was introduced and offered to patients at high risk for DCI. We compared the incidence and burden of DCI, neurological outcome, and the use of induced hypertension and endovascular rescue therapy in this consecutive aSAH population 3.5 years before versus 3.5 years after STX-VCS became available. Results- Four hundred thirty-six consecutive patients were included: 222 BEFORE and 214 AFTER. Fifty-seven of 214 (27%) patients received STX-VCS. Stereotactic procedures resulted in one (2%) subdural hematoma. Favorable neurological outcome at 6 months occurred in 118 (53%) patients BEFORE and 139 (65%) patients AFTER (relative risk, 0.79 [95% CI, 0.66-0.95]). DCI occurred in 40 (18.0%) patients BEFORE and 17 (7.9%) patients AFTER (relative risk, 0.68 [95% CI, 0.57-0.86]), and total DCI volumes were 8933 (100%) and 3329 mL (36%), respectively. Induced hypertension was used in 97 (44%) and 30 (15%) patients, respectively (relative risk, 0.55 [95% CI, 0.46-0.65]). Thirty (13.5%) patients BEFORE versus 5 (2.3%) patients AFTER underwent endovascular rescue therapies (relative risk, 0.17 [95% CI, 0.07-0.42]). Conclusions- Selecting high-risk patients for STX-VCS reduced the DCI incidence, burden, and related mortality in a consecutive aSAH patient population. This was associated with an improved neurological outcome.
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Affiliation(s)
- Roland Roelz
- From the Department of Neurosurgery (R.R., C. Scheiwe, I.C., C. Steiert, J. Buttler, E.R., J.G., M.J.S., J. Beck), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | | | - Christian Scheiwe
- From the Department of Neurosurgery (R.R., C. Scheiwe, I.C., C. Steiert, J. Buttler, E.R., J.G., M.J.S., J. Beck), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Bastian Sajonz
- Department of Stereotactic and Functional Neurosurgery (B.S., V.A.C., P.C.R.), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Istvan Csok
- From the Department of Neurosurgery (R.R., C. Scheiwe, I.C., C. Steiert, J. Buttler, E.R., J.G., M.J.S., J. Beck), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Christine Steiert
- From the Department of Neurosurgery (R.R., C. Scheiwe, I.C., C. Steiert, J. Buttler, E.R., J.G., M.J.S., J. Beck), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Jürgen Buttler
- From the Department of Neurosurgery (R.R., C. Scheiwe, I.C., C. Steiert, J. Buttler, E.R., J.G., M.J.S., J. Beck), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Eva Rohr
- From the Department of Neurosurgery (R.R., C. Scheiwe, I.C., C. Steiert, J. Buttler, E.R., J.G., M.J.S., J. Beck), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Jürgen Grauvogel
- From the Department of Neurosurgery (R.R., C. Scheiwe, I.C., C. Steiert, J. Buttler, E.R., J.G., M.J.S., J. Beck), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Mukesch J Shah
- From the Department of Neurosurgery (R.R., C. Scheiwe, I.C., C. Steiert, J. Buttler, E.R., J.G., M.J.S., J. Beck), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology (K.E.), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology (W.-D.N., J. Bardutzky), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Jürgen Bardutzky
- Department of Neurology (W.-D.N., J. Bardutzky), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Jürgen Beck
- From the Department of Neurosurgery (R.R., C. Scheiwe, I.C., C. Steiert, J. Buttler, E.R., J.G., M.J.S., J. Beck), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery (B.S., V.A.C., P.C.R.), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery (B.S., V.A.C., P.C.R.), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany.,Fraunhofer Institute for Laser Technology, Aachen, Germany (P.C.R.)
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